*No  LOSS  ACCOUNT 


MODERN  MEDICINE 

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THE 


Profit  and  Loss  Account  of 
Modern  Medicine 


AND 

OTHER  PAPERS 


BY 
STUART  McGUIRE,  M.D.,  F.A.C.S. 

Profestor  of  Surgery,  Medical  College  of  Virginia;  Surgeon  in  charge 
St.   Luke's   Hospital;    Visiting    Surgeon,   Memorial    Hospital;  Ex- 
President  of  the  Richmond  Academy  of  Medicine  and  Surgery, 
of  the  Medical  Society  of  Virginia,  of  the  Tri-State  Medical 
Association  of  Virginia  and  the  Carolinas,  of  the  South- 
em  Surgical  and  Gynecological  Association,  of  the 
Southern  Medical   Association,  Etc. 


ILLUSTRATED 


RICHMOND.  VIRGINIA 
L.  H.  JENKINS,  Publisher 
1915 


Preface  or  Apology 


Having  occasion  to  refer  to  a  paper  I  had  written 
several  years  ago,  I  was  unable  to  find  a  reprint  of  it, 
or  the  issue  of  the  journal  in  which  it  appeared. 

This  led  to  an  effort  to  secure  a  copy  of  all  the 
articles  I  had  published  and  to  put  the  collection  in  shape 
for  personal  reference. 

The  possession  of  the  material  in  concrete  form  sug- 
gested the  possibility  of  making  it  into  a  book,  and  this 
at  first  rather  vague  idea  finally  became  a  desire  so  strong 
that  I  determined  to  gratify  it.  In  indulging  myself  I 
have  tried  to  show  consideration  for  my  prospective 
reader  by  not  printing  all  I  have  written. 

The  various  papers  have  been  arranged  with  refer- 
ence to  the  subjects  treated  rather  than  the  date  at  which 
they  appeared. 

While  I  have  serious  misgivings  as  to  the  merit  of 
the  volume,  I  have  no  doubts  as  to  the  extent  of  its  circu- 
lation, for  it  is  intended  for  private  distribution  and  will 
not  be  offered  for  sale. 

Stuart  McGuire. 

Richmond,  Va.,  May,  191 5. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/profitlossaccounOOmcgu 


CONTENTS 


The  Profit  and  Loss  Account  of  Modern  Medicine 7 

Latent  and  Active  Neurasthenia  in  Its  Relation  to  Surgery  31 

Evolution  of  the  Treatment  of  Ectopic  Pregnancy 49 

Cornual  Pregnancy  with  Report  of  a  Case 61 

Tradition  Versus  Embryology  in  Congenital  Malformation  67 

Treatment  of  Diffuse  Suppurative  Peritonitis 79 

The  Surgical  Treatment  of  Dyspepsia  87 

Analysis  of  the  Last  Five  Hundred  Cases  of  Appendicitis 

Operated  on  at  St.  Luke's  Hospital  95 

Some  Accepted  Facts  and  Mooted  Points  in  the  Manage- 
ment of  Appendicitis  107 

Appendicostomy      119 

Pylorospasm    129 

Etiology  and  Symptomatology  of  Gall  Stones  133 

Diagnosis  and  Treatment  of  Gall   Stones 143 

Analysis  of  the  Last   Fifty  Cases  of  Goitre  Operated  on 

at   St.   Luke's  Hospital  153 

The  Thyroid  and  Hyperthyroidism 165 

The  Diagnosis  and  Treatment  of  Hypothyroidism 191 

The   Influence   of  the   General   Condition   of   the   Patient 

on  the  Result  of  a  Surgical  Operation  197 

Surgical  Shock  213 

Sulphate  of  Spartine  in  Surgical  Practice 229 

The  After  Care  of  a  Surgical  Patient 233 

Past,  Present  and  Future  of  Cancer 245 

Methods  to  Hasten  Epidermization  With  Special  Reference 

to   Skin  Grafting  265 

To  Cut  or  Crush  in  Stone  of  the  Urinary  Bladder 277 

Extra    Peritoneal    Implantation    of   the    Ureters    into    the 

Rectum  in  a  Case  of  Exstrophy  of  the  Bladder 285 

Intestinal  Obstruction  from  Meckel's  Diverticulum 291 

Obstruction   of   the    Esophagus    with    Report    of    Illustra- 
tive  Cases   295 

Diaphragmatic  Hernia  with  Report  of  a  Case 305 


ILLUSTRATIONS 


opposit:!? 

PAGE 

Fig.  1.  Photograph  of  Patient  with  Three  Legs 69 

Fig.  2.  X-Ray  of  Knee  Joint  71 

Fig.  3.  X-Ray  of  Foot  73 

Fig.  4.  Bed  Elevator  81 

Fig.  5.  Bed    Seat   83 

Fig.  6.  Bed  in  Moderate  Elevation 85 

Fig.     7.     Specimens    of    Stones    Showing    Foreign    Bodies 

as   Nuclei   283 

Fig.  8.  Catheterization  of  Ureters  and  Beginning  Sepa- 
ration of  the  Bladder 287 

Fig.     9.     The  Bladder  Separated  and  Rectum  Exposed....  289 

Fig.  10.  The  Rectum  Opened  Ready  for  the  Transplanta- 
tion of  the  Bladder 293 

Fig.  11.     The  Transplantation  Completed 295 

Fig.  12.  Obstruction  of  Esophagus  Caused  by  Cardio- 
spasm       301 

Fig.  13.     Obstruction  of  Esophagus  Due  to  Stricture;  the 

Result   of  Typhoid   Fever 305 

Fig.  14.     Obstruction  of  Esophagus  Caused  by  Cancer  of 

the  Cardia  307 

Fig.  15.  X-Ray  of  First  Case  of  Diaphragmatic  Hernia 
Before  Operation  Showing  Stomach  in  Left  Thoracic 
Cavity    311 

Fig.  16.  X-Ray  of  Second  Case  of  Diaphragmatic  Hernia 
Before  Operation  Showing  Stomach  in  Left  Thoracic 
Cavity    313 

Fig.  17.     Incision    in    Operation    by    Thoracic    Route    for 

Diaphragmatic  Hernia  315 


The  Profit  and  Loss  Account  of 
Modern   Medicine  * 

Mr.  Chairman,  Fellows  of  the  Southern  Medical  Asso- 
ciation, Ladies  and  Gentlemen : 

My  first  duty  is  to  repeat  my  thanks  which  I  fear  were 
but  poorly  expressed  at  the  time  of  my  election  in  Lex- 
ington, Kentucky,  as  President  of  the  Southern  Medical 
Association. 

To  be  chosen  to  preside  over  a  body  of  more  than 
three  thousand  men,  representing  the  best  element  of  the 
medical  profession  in  the  sixteen  Southern  States,  is  a 
trust  and  honor  that  causes  mingled  feelings  of  humility 
and  pride.  No  one  elected  to  the  position  I  occupy  could 
believe  himself  worthy,  and  no  one  could  fail  to  be 
proud  of  his  good  fortune. 

It  is  especially  pleasing  to  preside  at  a  session  of  the 
Association  held  in  my  own  city,  and  to  be  one  of  many 
to  bid  you  welcome  to  Richmond  and  to  Virginia. 

The  subject  of  my  address  is  "The  Profit  and  Loss 
Account  of  Modern  Medicine."  Wonderful  progress  has 
been  made  in  medicine  during  recent  years,  but  the  profit 
has  been  attended  by  loss,  which  must  be  considered  in 
balancing  the  account.  In  taking  stock  of  the  gain  we 
will  find  inspiration  for  the  future;  in  counting  the  cost 
we  may  guard  against  the  undue  sacrifices  of  the  past. 


*  Address  at  the  meeting  of  the  Southern  Medical  Association, 
Richmond,  Va.,  November,  1914. 


7 


THE  PROFIT  AND  LOSS  ACCOUNT  OF 

Modern  Medical  Education. 

The  most  distinct  profit  and  loss  in  modern  medicine 
have  come  about  through  changes  in  medical  education, 
which  have  been  accomplished  largely  through  the  ef- 
forts of  the  American  Medical  Association,  the  Asso- 
ciation of  Amierican  Medical  Colleges,  and  the  Carnegie 
Foundation  for  the  Advancement  of  Teaching. 

It  was  recognized  that  each  year  a  progressively  in- 
creasing number  of  low  grade  practitioners  were  being 
graduated  by  medical  colleges  and  licensed  by  State  gov- 
ernments. An  investigation  of  the  medical  schools 
showed  that  many  of  them  were  poorly  equipped,  had 
scant  clinical  material  and  lacked  sufficient  funds  to  se- 
cure the  necessary  time  of  efficient  teachers. 

To  remedy  this  evil  a  deliberate  and  systematic  move- 
ment was  inaugurated  to  lessen  the  number  and  improve 
the  quality  of  the  men  who  are  being  added  to  the  ranks 
of  the  profession.  By  moral  suasion,  by  State  legisla- 
tion and  by  the  combined  efforts  of  the  better  schools,  the 
entrance  requiremients  were  advanced,  the  number  and 
length  of  the  teaching  sessions  were  increased,  the  char- 
acter and  scope  of  the  curricula  were  improved,  and 
the  minimum  number  and  approximate  pay  of  the  full 
time  teachers  were  specified. 

The  result  of  th's  movement  has  been  that  in  the  last 
ten  years  the  total  number  of  medical  schools  in  the 
United  States  has  been  reduced  from  i86  to  loi  and 
the  total  number  of  medical  students  from  28,142  to 
16,502.  In  other  words,  85  medical  schools,  weak  either 
educationally  or  financially,  have  ceased  to  teach,  and 
over  10,000  medical  students  not  properly  qualified  for 

8 


MODERN    MEDICINE 


the  profession  have  ceased  to  study.  And  the  end  is  not 
yet. 

In  no  section  of  the  country  has  this  campaign  been 
more  effective  than  in  our  own.  The  Council  of  the 
Amierican  Medical  Association,  in  its  last  report  said : 
"The  most  serious  problems  of  medical  education  are 
no  longer  to  be  found  in  the  South,  but  rather  in  some 
of  the  large  cities  of  the  East  and  North." 

The  benefit  of  this  movement  is  already  markedly  seen 
in  the  medical  colleges,  where  the  qualifications  of  the 
student  are  found  improved  and  the  character  of  the 
instruction  more  satisfactory.  A  medical  student  now 
begins  his  studies  with  a  knowledge  of  the  elementary 
sciences.  He  it  taught  the  fundamental  medical  facts  in 
laboratory  and  dissecting  hall  by  trained  instructors  who 
give  their  entire  time  to  the  work.  When  he  comes  to 
study  disease,  it  is  disease  in  people,  not  in  books.  He 
is  brought  to  the  bedside  of  the  patient  and  encouraged 
to  observe,  to  weigh  and  to  decide.  The  new  idea  in 
teaching  tends  to  make  of  the  student  an  active  investi- 
gator instead  of  a  passive  hearer,  and  of  the  teacher  a 
sympathetic  guide  rather  than  a  verbose  expositor. 

There  has  not  yet  been  time  for  the  benefit  of  the 
change  to  be  very  apparent  in  actual  practice,  but  the 
lessened  number  and  improved  quality  of  the  graduates 
turned  out  each  year  will  unquestionably  in  the  end  re- 
sult in  a  great  improvement  in  the  ethics  and  efficiency 
of  the  profession. 

The  profit,  however,  has  not  been  without  its  loss, 
and  while  we  congratulate  ourselves  on  what  has  been 
gained  by  this  educational  movement,  it  is  only  just  to 

9 


THE  PROFIT  AND  LOSS  ACCOUNT  OF 

count  what  it  has  cost.  Many  worthy  although  struggling 
colleges  have  been  put  out  of  existence  and  their  prop- 
erty practically  confiscated,  and  many  earnest  and  promis- 
ing young  men  have  been  denied  an  opportunity  to  study 
medicine  because  of  some  defect  in  their  preliminary 
high-school  or  college  education.  Again  the  modern  medi- 
cal school  is  not  self-supporting  and  is  a  heavy  financial 
tax  on  public  funds  or  private  philanthropy.  Expensive 
laboratories,  salaries  of  full  time  instructors  and  the 
necessary  provisions  for  clinical  teaching,  impose  a  cost 
that  can  never  again  be  met  by  tuition  fees.  Each  matri- 
culate is  an  added  burden,  and  the  school  of  today  finds 
itself  in  a  vicious  circle;  the  better  it  teaches  the  more 
students  it  gets,  the  more  students  it  gets  the  more 
money  it  loses.  If  each  student  were  charged  what 
it  actually  cost  to  teach  him,  none  but  the  rich  could  af- 
ford to  study  medicine.  Doctors  are  a  necessity,  not  a 
luxury,  and  as  the  rich  do  not  care  to  become  doctors, 
then  the  rich  in  the  future  will  have  to  be  educated  to 
contribute  of  their  wealth  to  make  doctors.  Medical  edu- 
cation has  ceased  to  be  a  business  and  become  a  philan- 
thropic work  which  must  be  supported  by  State  appro- 
priations and  individual  benefactions. 

Finally,  the  cost  of  the  modern  method  of  teaching  is 
seen  in  the  graduate  himself.  If  he  has  not  paid  in 
money  he  has  been  made  to  pay  in  time  for  his  edu- 
cation. He  has  been  kept  in  laboratory,  lecture  hall  and 
hospital  ward,  a  non-producer,  dependent  on  others  for 
his  support,  until  he  reaches  an  age  at  which  most  of 
his  contemporaries  are  married  and  settled  in  life.  He 
is  conscious  of  the  sacrifice  he  has  made,  and  usually 
over  appreciative  of  the  attainments  he  has   acquired. 

10 


MODERN    MEDICINE 


He  desires  to  be  a  specialist,  and  will  only  do  general 
practice  as  a  means  to  an  end.  He  is  determined  to 
locate  in  a  city  and  unwilling  to  settle  in  the  country, 
preferring  to  starve  himself  in  the  one  rather  than  to 
starve  his  ambitions  in  the  other. 

This  results  in  an  urban  congestion  and  rural  deple- 
tion of  medical  men  which  has  reached  a  point  to  give 
serious  concern,  and  for  which  some  remedy  must  be 
found.  It  has  been  proposed  that  special  medical  schools 
be  operated  to  produce  low-grade  practitioners  for  coun- 
try consumption,  but  this  is  impracticable  and  unthink- 
able. 

The  remedy  for  the  evil  is  to  make  country  practice 
less  arduous  and  more  profitable,  and  this  will  come 
about  in  time  with  the  evolution  of  our  social,  economic 
and  political  life.  When  we  compare  the  conditions  that 
exist  in  the  country  today  with  those  which  existed 
even  twenty  years  ago,  and  recall  the  changes  that  have 
resulted  from  the  good-roads  movement,  the  development 
of  the  automobile,  the  installation  of  telephones,  the  in- 
troduction of  parcel  post  and  rural  mail  delivery,  the  im- 
provement of  the  public  school  system,  the  perfection  of 
heating  and  lighting  plants  and  the  invention  of  labor 
saving  machinery,  it  is  not  difficult  to  believe  that  in  the 
not  far  distant  future,  the  increased  population  due  to 
emigration  of  health  and  pleasure  seekers  from  the  city, 
and  the  increased  prosperity  due  to  intensified  and  scien- 
tific farming,  will  make  the  life  of  the  country  doctor 
one  that  will  attract  and  hold  the  best  representatives  of 
the  profession. 

Having  considered  the  profit  and  loss  account  of 
modern  medical  education,  we  now  come  to  what  we  have 

II 


THE  PROFIT  AND  LOSS  ACCOUNT  OF 

gained  and  lost  in  the  doctor  himself.  The  physician  of 
the  old  school  was  usually  a  gentleman  by  birth  and  breed- 
ing. He  was  given  a  classical  education  not  because  of 
his  future  profession,  but  because  it  was  a  privilege  ac- 
corded his  brothers  as  well  as  himself,  without  refer- 
ence to  their  future  vocations  in  life.  His  preparation 
for  practice  consisted  in  reading  medicine  for  a  few 
months  in  a  preceptor's  office  and  then  attending  lectures 
for  one  or  two  years  at  a  medical  college.  His  very  lack 
of  technical  training  gave  him  independence  and  resource- 
fulness, and  with  experience  he  gained  an  ability  to  make 
a  diagnosis  by  intuition  and  to  apply  treatment,  which, 
while  often  empirical  was  usually  effective.  He  was  no 
specialist,  but  attended  every  member  of  a  household, 
because  a  family  was  a  unit  and  his  art  was  catholic. 
He  knew  the  constitution  of  his  patient  because  neigh- 
bor married  neighbor  and  lived  where  they  were  born. 
He  was  not  only  physician  but  friend,  confidant  and 
counsellor  as  well.  In  his  personal  affairs  he  was  un- 
business-like,  rarely  sending  bills  and  accepting  such  hon- 
oraria as  were  tendered  him  in  settlement  of  his  accounts. 
In  public  affairs  he  was  prominent  and  his  views  and 
opinions  had  weight  in  matters  of  church  and  State.  He 
had  his  weaknesses  and  his  faults.  Measured  by  modern 
standards  he  was  ignorant  and  sometimes  mischievous, 
but  he  served  well  his  day  and  generation  and  was  a 
most  lovable  old  aristocrat. 

The  modern  medical  man  begins  to  be  trained  for  his 
profession  while  yet  a  boy.  His  preliminary  education 
in  high-school  and  college  is  scientific  rather  than  classi- 
cal, and  gives  him  knowledge  rather  than  culture.  When 
he  completes  his  four  year's  course  in  a  medical  college 

12 


MODERN    MEDICINE 


1/ 


and  one  year  post-gradnate  work  in  a  hospital,  he  repre- 
sents an  investment  of  time  and  money  covering  a  period 
of  from  fourteen  to  sixteen  years.  He  is  no  longer  a 
boy,  but  an  eminently  practical  man,  and  he  regards  his 
calling  as  more  a  business  than  a  profession.  He  recog- 
nizes the  fact  that  he  lives  in  an  age  of  specialization, 
that  no  one  man  can  now  meet  all  the  professional  needs 
of  a  patient,  and  that  the  day  of  the  domination  of  the 
family  physician,  on  the  one  hand,  and  the  dependence 
of  the  family  on  the  other,  has  passed.  He  understands 
that  with  the  freedom  now  customary  of  choosing  differ- 
ent attendants  to  treat  separate  ailments,  the  factors  of 
social    position,    family   connection,    and    even   personal 

friendship  count  for  little,  but  that  a  doctor  is  employed 
because  he  is  believed  to  be  the  most  efficient  man  avail- 
able to  relieve  the  patient  or  cure  the  disease.  He  recog- 
nizes the  necessity  of  sobriety,  industry,  honesty  and 
clean  living,  but  he  also  knows  that  the  public  no  longer 
measures  experience  by  age,  virtue  by  matrimony,  or 
morality  by  affiliation  with  the  Church,  and  that  the  first 
and  last  prerequisite  for  success  is  professional  ability. 

Such  being  the  situation  with  which  he  has  to  deal  the 
modern  medical  man  early  chooses  a  special  line  of  work, 
and  devotes  every  effort  and  utilizes  every  opportunity  to 
perfect  himself  and  impress  the  community  with  his  pro- 
ficiency. His  attitude  to  the  public  has  changed,  and  he 
no  longer  cloaks  his  reasons  in  secrecy  or  his  actions  in 
mystery,  but  deals  frankly  with  his  patients,  explains 
cause  and  effect,  and  secures  their  co-operation  in  car- 
rying out  treatment.  The  modern  doctor  has  discarded 
the  silk  hat  and  frock  coat  of  his  predecessor  and  put 
on  the  sack  suit  of  the  business  man.     In  a  sense  he  has 

13 


THE  PROFIT  AND  LOSS  ACCOUNT  OF 


become  commercial.  His  offices  are  not  only  provided 
with  instruments  of  diagnostic  precision,  but  also  with 
modern  methods  of  keeping  accounts  and  collecting  fees. 
From  the  foregoing  crude  pen  picture  must  be  in- 
ferred what  has  been  the  profit  and  what  the  loss  to  the 
public  and  to  the  profession  from  the  modern  doctor. 
We  have  lost  a  character  dear  to  literature,  and  gained 
a  type,  perhaps  less  ethical  and  more  mercenary,  but 
which  is  certainly  a  scientific  instrument  of  greater  pro- 
fessional efficiency. 

The  Modern  Specialist. 

The  development  of  the  modern  specialist  is  a  source 
of  both  profit  and  loss  to  medicine.  The  profit  is  too 
apparent  to  need  emphasis.  The  specialist,  by  concen- 
tration of  study  and  limitation  of  practice  to  certain  defi- 
nite organs  or  diseases,  is  able  in  a  few  years  to  acquire 
greater  diagnostic  skill  and  more  successful  methods  of 
treatment  in  his  special  line  of  work  than  another  man 
of  equal  ability  would  obtain  in  a  lifetime  of  general 
practice. 

The  presence  of  a  specialist  in  a  community  not  only 
gives  to  patients  suflFering  with  certain  diseases  oppor- 
tunities for  efficient  treatment,  but  also  offers  to  the  sur- 
geon and  general  practitioner  a  consultant  whose  opinion 
and  advice  are  often  invaluable  in  the  determination  of  the 
cause  of  obscure  symptoms,  and  in  the  decision  as  to  the 
therapeutic  treatment  or  operative  intervention  most  like- 
ly to  effect  a  cure.  While  the  profit  side  of  the  special- 
ists account  is  large,  still  on  the  opposite  page  we  find 
some  items  of  loss.  The  high  esteem  in  w^hich  the  special- 
ist is  held,  the  pecuniary  rewards  which  his  services  com- 

14 


MODERN    MEDICINE 


mand  and  the  advertising  opportunities  offered  by  his 
position,  have  made  him  a  victim  of  imitators  and  im- 
postors, both  inside  and  outside  the  pale  of  the  profes- 
sion, who  deceive  and  defraud  the  pubHc.  Modern  medi- 
cine is  not  responsible  for  the  quacks  and  charlatans,  but 
it  is  responsible  for  the  members  of  the  regular  profes- 
sion found  in  every  town  and  city  who  claim  to  be 
specialists,  but  who  really  do  a  general  practice,  and  for 
others  who,  while  they  may  limit  their  work  to  certain 
diseases,  are  not  qualified  as  experts,  and  have  no  more 
knowledge  or  experience  in  their  diagnosis  and  treatment 
than  the  average  general  practitioner. 
^^  Again  the  specialist,  although  an  expert,  is  often  nar- 
row in  his  views  and  prejudiced  in  his  opinions,  so  that 
he  finds  explanation  for  every  symptom  in  the  derange- 
ment of  the  organs  he  treats.  His  patients  often  suffer 
from_special  attention  and  general  neglect.  Motes  are 
pulled  out  of  the  eyes  and  beams  are  left  in  the  belly,  or 
the  abdomen  is  invaded  for  real  or  supposed  appendi- 
citis and  the  lungs  are  left  to  fight  their  own  battle  with 
tuberculosis. 

Finally,  the  specialist  is  an  expensive  friend  of  both 
the  patient  and  the  general  profession.     It  is  an  every- 
day experience  for  the  surgeon  or  general  practitioner  to 
send  an  obscure  case,  first  to  the  pathologist  for  the  ex- 
amination of  his  blood,  urine,  sputum,  feces  or  stomach 
contents,  then  perhaps  in  turn  to  the  roentgenologist,  the 
cystoscopist,  the  ophthalmologist  and  the  dermatologist. 
V  The  patient  goes  the  rounds  submitting  his  anatomy  and 
[     functions  to  exhaustive  examinations  and  reports,  and  his 
I    pocketbook  to  depletion.     The  system  is  not  essentially 
wrong.     Unquestionably  the  patient  is  better  cared  for 

15 


^ 


} 


THE  PROFIT  AND  LOSS  ACCOUNT  OF 

than  formerly.  To  the  well-to-do,  while  the  cost  is  great, 
it  is  not  prohibitory.  To  the  poor,  the  public  and  private 
charities  are  open  where  they  can  get  the  same  services, 
dispensed  in  less  luxurious  fashion,  but  no  less  efficiently. 
The  real  sufferer  in  the  transition  stage  of  rapid  differen- 
tiation and  delayed  organization  is  the  great  middle  class. 
Caught  between  penury  and  pride,  without  the  price  to 
pay,  but  with  the  desire  to  conceal  their  poverty,  they  are 
often  limited  to  an  inferior  grade  of  service. 

Team  work  is  essential  to  carry  out  the  modern  sys- 
tem of  examinations.  It  is  best  seen  in  the  staff  of  a 
modern  hospital  where  ever  patient  has  at  his  command 
the  services  of  specialists  in  all  diagnostic  lines.  The 
same  principle  must  sooner  or  later  come  into  vogue  in 
private  practice.  Ultimately  doctors  will  have  their  offices 
in  large  buildings  .instead  of  at  their  private  residences. 
Here  composite  groups  will  unite  in  close  business  and 
professional  association  as  a  firm  or  corporation.  Pa- 
tients will  be  treated  jointly,  conveniently  and  expediti- 
ously, and  a  combined  bill  will  be  presented  through  a 
central  office. 

Modern  Diagnostic  Methods. 

One  of  the  most  wonderful  gains  made  in  modern 
medicine  is  in  the  exact  diagnosis  of  disease  by  laboratory 
methods.  For  a  time  our  knowledge  of  etiology  and 
pathology  was  vague  and  indefinite,  but  one  after  another, 
great  discoverers  have  cleared  the  field  and  given  us 
definite  facts  with  which  to  work.  Diatheses  and  dys- 
crasias,  miasmatic  and  idiopathic  diseases  are  no  longer 
mentioned ;  the  terms  scofula,  blood  poison  and  typho- 
malarial   fever  are   no   longer  employed,  and   even   the 

i6 


MODERN    MEDICINE 


identity  of  neurasthenia  and  auto-intoxication  are 
questioned. 

We  now  diagnose  the  existence  of  tuberculosis,  not  by 
hectic  fever,  but  by  the  demonstration  of  Koch's  bacillus. 
We  diagnose  malaria,  not  by  the  therapeutic  test  of 
quinine,  but  by  the  presence  of  the  plasmodium  of  Laver- 
an.  Wldal  has  given  us  the  agglutination  test  for  typhoid, 
and  Wasserman  the  reaction  which  shows  the  presence  or 
absence  of  syphilis.  The  white  blood  count  tells  the 
degree  of  infection  and  resistance  of  the  patient,  and  is 
not  only  a  test  of  importance  in  making  prognosis,  but 
often  indicates  the  proper  time  for  intervention.  The 
microscopic  examination  of  tissue  differentiates  benign 
from  maligant  tumors,  and  in  operation  for  cancer  the 
frozen  section  will  often  tell  the  surgeon  when  he  has 
reached  the  limit  of  the  disease.  The  X-ray  shows  the 
existence  of  fractures  and  the  position  of  fragments, 
locates  the  presence  of  stones  in  the  kidney,  ureter  or 
bladder,  and  by  recent  perfection  of  technique  makes 
moving  pictures  showing  the  passage  of  food  from  the 
stomach  to  the  rectum. 

The  inspection  of  the  modern  laboratory  is  impressive 
to  the  visitor.  The  rows  of  reagents,  retorts  and  test 
tubes;  the  microscopes,  centifuges  and  microtomes;  the 
refrigerators,  incubators  and  culture  media ;  the  polaris- 
copes,  hematocytometers,  sphygmomanometers  and  other 
instruments  of  precision,  make  a  layman,  and  even  some 
of  the  profession,  think  that  the  work  done  and  the  final 
report  made  must  settle  all  questions  in  a  given  case. 

But  the  laboratory  method  of  diagnosis  entails  a  loss 
as  well  as  a  gain  and  has  its  dangers  and  disadvantages. 
While  it  is  true  that  chemical  reactions  are  always  con- 

17 


THE  PROFIT  AND  LOSS  ACCOUNT  OF 

stant,  that  the  microscopic  field  shows  the  cellular  struc- 
ture of  tissue  and  the  physical  form  of  bacteria,  and  that 
the  X-ray  picture  truly  depicts  the  shadow  of  the  object 
between  the  Crooke's  tube  and  the  photographic  plate,  it 
must  always  be  remembered  that  there  is  a  personal  and 
uncertain  factor  in  the  result,  namely,  the  laboratory  man 
who  construes  what  he  sees.  A  poor  pathologist  or 
Roentgenologist  is  worse  than  none  at  all,  and  even  the 
opinion  of  the  most  experienced  and  proficient  is  oc- 
casionally wrong. 

As  valuable  as  are  his  services,  the  laboratory  man  is 
sometimes  too  highly  regarded.  Seated  upon  his  kingly 
stool  and  surrounded  by  a  rarefied  scientific  atmosphere, 
he  tends  to  tyrannize  the  clinician.  His  reports  are  too 
often  accepted  as  final  in  their  decrees  and  become  ener- 
vating in  their  influence.  Owing  to  a  tendency  to  lean 
too  much  on  laboratory  reports,  case  histories  and  bed- 
side records,  the  profession  is  in  danger  of  neglecting  the 
examination  of  the  patient.  Sick  people  are  just  as  in- 
structive today  as  in  the  time  of  Sydenham,  Addison  and 
Bright.  Laboratory  data  and  clinical  findings  must  be 
studied  together.  They  must  be  compared,  and  one  used 
to  check  a  possible  error  of  the  other. 

The  Modern   Hospital. 

The  hospital,  while  an  old  institution,  is  modern  in  its 
distribution  and  function.  It  has  lived  down  its  stigma 
of  a  death  house.  It  has  overcome  the  prejudices  of  the 
masses  and  appealed  to  the  pride  of  the  classes.  Prac- 
tically every  town  of  five  thousand  inhabitants  has  a  hos- 
pital, and  every  well-regulated  hospital  is  an  asset  to  its 
community.     A  hospital  is  now  accepted  as  the  safest 

i8 


MODERN    MEDICINE 


most  comfortable  and  most  economical  place  for  the 
seriously  sick,  and  it  is  also  recognized  as  a  local  centre 
for  the  dissemination  of  knowledge  among  the  public,  the 
training  and  education  of  nurses,  and  the  uplift  of  the 
profession  by  the  demands  made  for  good  records, 
thorough  examinations,  accurate  diagnoses  and  rational 
treatment. 

Many  hospitals  through  a  mistaken  sentimentality  on 
the  part  of  Boards  of  Managers  refuse  to  allow  clinics  to 
be  held  in  their  wards.  By  this  prohibition  they  do  not 
protect  the  patients  from  anything  to  which  they  object, 
but  expose  them  to  a  possible  danger  from  which  they 
could  be  shielded.  Experience  has  shown  that  sick  peo- 
ple are  egotists,  and  that  the  more  they  are  examined 
and  discussed  the  better  they  are  pleased ;  also  that  the 
greatest  safeguard  against  neglect  or  improper  treatment 
on  the  part  of  the  staff,  is  the  knowledge  that  the  work- 
done  is  under  the  constant  observation  and  critic'sm  of 
students  and  physicians  who  visit  the  institution.  The 
hospital  of  the  future  should  not  only  care  for  its  patients, 
but  also  be  a  centre  for  medical  research,  a  stimulus  for 
the  understanding  v'sitor,  and  a  training-school  for  nur- 
ses, students  and  doctors. 

The  modern  hospital,  however,  is  not  without  its  dan- 
gv.rs  and  disadvantages,  as  it  offers  opportunity  and  hence 
temptation  to  members  of  its  staff,  especially  those  with 
surgical  ambition,  to  undertake  work  for  which  they  are 
not  qualified.  The  following  is  a  familiar  illustration : 
A  small  town  feels  the  need  of  a  hospital,  the  women 
organize,  ra^'se  the  money  and  build  one.  The  people  of 
this  community  had  formerly  made  it  a  practice  to  go 

19 


THE  PROFIT  AND  LOSS  ACCOUNT  OF 

to  some  neighboring  city  when  in  necl  of  special  medical 
treatment  or  a  serious  surgical  operation.  They  are  now 
urged  to  patronize  the  home  hospital,  and  as  that  course 
appeals  to  their  desire  to  help  a  local  institution,  and 
also  avoids  separation  from  family  and  friends,  the  ad- 
vice is  often  followed.  For  a  time  an  experienced  sur- 
geon is  sent  for  to  operate  on  difficult  cases,  and  one  of 
the  local  practitioners  acts  as  his  assistant.  The  success- 
ful result  which  usually  follows  in  these  early  cases  in- 
spires the  community  with  confidence  in  the  hospital,  and 
in  time  creates  a  desire  in  the  mind  of  the  local  man  to 
do  the  work  himself.  He  spends  six  weeks  or  three 
months  at  a  post-graduate  school,  and  returns  with  a 
h'ghly  embellished  certificate.  He  performs  a  herniotomy 
or  removes  an  appendix,  and  the  pat'ent  does  not  die. 
He  comes  to  be  known  in  the  community  as  a  man  of 
wonderful  nerve.  He  hopes  later  to  drop  his  other  work 
and  do  nothing  but  surgery. 

The  evil  goes  further.  This  newly  developed  surgeon 
has  no  regular  assistant,  and  makes  it  a  rule  to  get  the 
family  doctor  of  the  patient  to  help  him  with  the  opera- 
tion. As  the  physician  does  part  of  the  work  it  seems 
only  proper  that  he  should  get  part  of  the  fee.  When 
this  practitioner  has  a  patient  who  desires  to  go  to  a 
specialist  in  a  large  city,  what  is  more  natural  than  that 
he  should  go  with  him,  and  explain  that  he  was  reluctant 
to  come  because  of  the  loss  of  the  financial  benefit  he  was 
accustomed  to  receive  from  such  cases  at  home ;  or  what 
more  human  than  for  the  city  surgeon  to  endeavor  to 
meet  this  competition  by  ofifering  to  split  the  fee  in  this 
and  future  cases  provided  it  was  made  sufficiently  large ; 
and  what  more  necessary  than  that  this  secret  understand- 

20 


MODERN    MEDICINE 


ing  between  the  two  be  kept  from  the  knowledge  of  the  pa- 
tient. And  so  has  come  about  the  great  modern  evil  of 
the  secret  division  of  the  fee,  a  practice  by  which  the  doc- 
tor sells  the  patient  to  the  highest  bidder,  and  by  which  the 
surgeon  robs  the  patient  to  pay  the  doctor.  Happily  this 
practice  does  not  exist  in  Virginia,  and  is  limited  to  a 
very  few  communities  in  the  South.  Wherever  it  does 
occur  it  is  denounced  in  strong  and  unmeasured  terms  by 
the  best  element  of  the  local  profession. 

The  evil  of  incompetency  in  the  shape  of  the  unquali- 
fied surgeon,  and  the  vice  of  dishonesty  in  the  form  of  the 
secret  division  of  the  fee,  are  being  fought  in  the  pro- 
fession by  the  establishment  of  a  special  organization 
known  as  "The  American  College  of  Surgeons."  If  the 
remedy  is  not  found,  action  will  be  taken  sooner  or  later 
by  an  indignant  public  through  State  legislation. 

The  Modern  Trained  Nurse. 

The  advent  of  the  trained  nurse  marked  an  epoch  in 
medicine  almost  equal  to  the  introduction  of  anesthesia 
and  antiseptics,  and  the  name  of  the  founder  of  the  order, 
Florence  Nightingale,  deserves  to  rank  with  those  of 
Long,  Pasteur  and  Lister.  The  rapid  and  general  adop- 
tion of  the  trained  nurse  was  due,  not  only  to  the  pro- 
fessional needs  of  the  doctor,  but  also  to  the  domestic 
necessities  of  the  public.  In  times  past  a  sick  person  was 
nursed  by  servants  and  relatives.  In  every  family  there 
were  old  mammies  and  old  maids  who  had  considerable 
practical  experience  in  nursing,  and  who  derived  a  cer- 
tain morbid  pleasure  from  the  temporary  authority  of  the 
sick  room.  The  modern  servant  problem,  and  the  recent 
migration  of  the  unmarried  female  members  of  the  family 

21 


THE  PROFIT  AND  LOSS  ACCOUNT  OF 

from  the  home  to  the  office,  did  away  with  this  supply  of 
amateur  nurses,  and  created  a  demand  for  the  profes- 
sional nurse. 

At  one  time,  especially  in  the  South,  there  were  but 
two  respectable  things  for  a  young  woman  to  do,  get 
married  or  teach  school.  Now  many  avenues  are  open 
to  them,  and  of  these  none  is  more  attractive  or  offers 
greater  opportunities  for  service  than  the  field  of  nurs- 
ing. 

In  the  early  part  of  the  last  century  the  only  paid  nurse 
was  a  servant,  without  education  or  technical  knowledge. 
In  America  today  the  professional  nurse  is  a  woman  .of 
good  social  position,  adequate  general  education  and 
trained  in  the  art  of  her  calling  by  three  years  practice 
and  study  in  a  hospital. 

Time  will  not  permit  an  attempt  to  show  the  contribu- 
tions of  the  trained  nurse  to  the  progress  of  medicine. 
In  every  department  she  has  proved  a  faithful,  efficient 
and  trusted  worker,  without  whose  aid  the  end  attained 
could  not  have  been  accomplished.  At  the  bedside  of  the 
patient  in  the  silent  vigils  of  the  night,  in  the  operating 
room  during  the  stress  and  strain  of  nerve-racking  or- 
deals, and  today  in  Europe  on  battlefields  torn  with  shell 
and  red  with  carnage,  she  has  shown  a  courage,  a  fixity 
of  purpose  and  a  devotion  to  duty  rarely  equaled  in  either 
sex  or  in  any  profession. 

The  nurse  is  a  woman,  and  therefore  has  her  faults, 
but  the  faults  are  those  of  the  woman,  not  of  the  nurse. 
If  she  is  sometimes  spoiled,  occasionally  a  trifle  tyranni- 
cal, and  more  rarely  a  bit  supercilious  from  real  or  sup- 
posed superiority  of  knowledge,  it  shows  the  weakness  of 
her  sex  and  not  of  her  profession.     If  her  services  are 

22 


MODERN    MEDICINE 


sometimes  prostituted  to  pamper  the  whims  of  the  neuras- 
thenic invahd,  or  to  indulge  the  selfish  indolence  of  the 
idle  rich,  it  is  not  her  fault,  hut  the  fault  of  our  present 
system  of  living. 

<^  'The  Modern  Medical  Society. 

The  medical  society  is  an  important  factor  in  the  pro- 
gress and  development  of  medicine.  While  some  mem- 
bers of  the  profession  do  not  appreciate  the  advantages  to 
be  derived  from  regular  attendance  and  active  co-opera- 
tion in  medical  organizations,  it  is  a  fact  that  the  busy  and 
successful  practitioners  are  usually  present  at  all  the  meet- 
ings of  their  County,  State  and  National  Associations. 
This  can  only  be  explained  by  the  fact  that  those  of  the 
profession,  whose  experience  and  judgment  have  proven 
to  be  the  soundest,  believe  that  medical  meetings  are 
profitable. 

Medical  societies  usually  hold  their  regular  sessions 
in  different  cities,  and  their  meetings  educate  and  stimu- 
late the  local  profession,  and  advertise  to  the  laity  the 
fact  that  medicine  is  not  bound  by  dicta  and  dogmas,  but 
is  a  progressive  science  ready  to  discard  the  old,  if  it  is 
proved  to  be  fallacious,  and  to  adopt  the  new,  if  it  is 
found  to  be  of  value.  The  meeting  of  a  medical  society 
enables  its  members  to  read  papers,  thus  giving  them  a 
legitimate  opportunity  to  show  their  capacity ;  and  to 
present  new  and  original  views  as  to  the  treatment  of 
disease,  thus  adding  to  the  knowledge  of  the  profession.  J 
It  enables  its  members  to  hear  papers  read  by  others,  thus 
giving  them  an  opportunity  to  gain  an  amount  of  infor- 
mation they  could  get  in  no  other  way  with  so  little  labor 
and  in  so  short  a  length  of  time.     The  discussions  that 

2Z 


THE  PROFIT  AND  LOSS  ACCOUNT  OF 

follow  these  papers  are  especially  profitable.  In  them 
is  an  impressive  personal  element  that  is  totally  lost  in 
the  stenographic  report  published  in  the  transactions. 

In  addition  to  the  educational  and  professional  advan- 
tages derived  from  these  meetings  there  are  equally  im- 
portant social  and  personal  benefits.  The  occasion  is  a 
holiday,  a  recreation,  a  vacation.  It  breaks  the  monot- 
ony of  life  and  enables  a  man  to  do  better  work  when  he 
returns  home.  It  offers  the  opportunity  to  meet  men  who 
are  doing  the  same  kind  of  work  in  different  sections  of 
the  country,  and  results  in  pleasing  and  profitable  ac- 
quaintanceships which  often  lead  to  permanent  friend- 
ships. And  last  but  not  least,  it  brings  together  men 
who  live  in  the  same  community,  but  who  owing  to  petty 
jealousies  or  lack  of  time  for  social  intercourse,  see  little 
of  each  other.  Either  in  the  session  of  the  society,  or  in 
the  committee  room,  or  on  the  journey  to  and  from  the 
place  of  meeting,  they  are  thrown  into  an  intimate  con- 
tact which  frequently  leads  to  explanation  of  misunder- 
standings, adjustment  of  differences,  appreciation  of  good 
qualities,  and  to  the  establishment  of  the  most  friendly 
and  cordial  relations. 

Despite  the  manifest  and  manifold  benefits  of  the  medi- 
cal society,  it  is  necessary  from  the  profit  to  deduct  a 
loss.  There  are  many  medical  societies  which  have  no 
right  of  being,  and  have  been  organized  simply  for  poli- 
tical or  personal  motives.  Originally  established  to  give 
office  or  secure  patronage  for  a  certain  group  of  men, 
they  are  often  supported  for  years  through  a  mistaken 
pride  or  patriotism  on  the  part  of  their  members,  to  the 
great  injury  of  the  legitimate  societies  whose  territory 
they  cover.    There  is  need  for  a  movement  to  standardize 

24 


MODERN    MEDICINE 


medical  associations,  and  until  this  is  done  through  the 
proper  channel  the  profession  should  try  to  minimize  the 
evil  by  withdrawing  its  membership  from  superfluous  or- 
ganizations. Leaving  out  of  consideration  the  societies 
of  the  specialists  there  are  but  four  medical  associations 
entitled  to  support:  the  county,  the  state,  the  regional 
and  the  National.  Each  organization  should  be  self-gov- 
erned, but  each  should  have  its  representatives  in  the  next 
higher  body,  and  all  work  together  for  the  common  good 
of  the  profession  and  people. 

Woodrow  Wilson,  in  speaking  of  the  new  banking  sys- 
tem, said :  "We  have  developed  by  regions  and  there  is 
every  reason  why  we  should  function  by  regions."  It  is 
because  the  South  has  developed  as  a  region  and  is  drawn 
together  by  a  common  spirit  that  we  are  met  together  to- 
day. The  Southern  Medical  Association  is  not  a  section- 
al, but  a  regional  society. 

Twenty  years  ago  it  was  considered  derogatory  to  the 
dignity  of  one  clinician  to  visit  the  workshop  of  another. 
To  do  so  would  be  to  invite  the  criticism  of  a  confessed 
inferiority,  or  of  a  desire  to  spy  on  the  work  of  a  com- 
petitor. Then  all  one  practitioner  knew  of  the  work  of 
the  other  was  through  printed  matter,  and  some  things 
that  were  true  were  not  believed  and  some  things  that 
were  not  true  were  accepted.  It  has  now  become  almost 
a  custom  for  the  busy  surgeon  and  physician  to  devote 
two  or  three  weeks  of  the  period  previously  assigned  for 
a  vacation  to  the  duty  of  seeing,  at  first  hand,  what  his 
fellows  are  doing.  At  the  various  recognized  medical 
centres  every  provision  is  made  for  the  convenience  and 
instruction  of  visiting  doctors.  No  fees  are  charged  and 
the  veriest  stranger  is  made  to  feel  welcome.    By  actually 

25 


THE  PROFIT  AND  LOSS  ACCOUNT  OF 


observing  the  methods  practiced  in  these  various  clinics 
the  visitor  is  able  to  decide  whether  or  not  they  are  pre- 
ferable to  the  technique  he  has  hitherto  employed. 

Surgeons,  as  a  rule,  attend  clinics  more  frequently 
than  do  physicians.  This  is  a  pity,  for  even  in  a  strictly 
surgical  clinic  the  points  of  greatest  interest  are  not  the 
methods  of  operating,  but  the  explanation  of  symptoms 
by  the  pathological  conditions  found.  It  is  a  curious 
fact  that  many  physicians,  who  would  travel  miles  to 
see  a  post-mortem  examination,  will  not  go  around  the 
corner  to  witness  an  operation  which  demonstrates  the 
same  changes  produced  by  disease  in  living  tissues  before 
they  are  obscured  by  terminal  results.  To  correct  the 
loss  entailed  by  the  failure  of  the  average  physician  to 
avail  himself  fully  of  the  advantages  offered  by  the 
modem  clinic  the  internist  must  learn  that  to  keep  abreast 
of  the  times  it  is  necessary  not  only  to  study  but  to  travel 
as  well. 

Europe,  in  time  of  peace,  may  offer  peculiar  advan- 
tages for  instruction  in  medical  subjects,  but  America 
can  truly  claim  to  have  the  best  surgical  clinics  in  the 
world.  Rochester,  Chicago,  Cleveland,  Philadelphia  and 
Baltimore  are  universally  known  for  their  surgical  teach- 
ing, and  some  of  our  Southern  cities  are  beginning  to  be 
the  objective  points  of  the  seekers  for  surgical  knowledge. 

Public  Health  Service. 

For  centuries  the  world  suffered  from  pestilence  and 
scourge.  People  in  desperation  abandoned  themselves  to 
their  fate,  discarded  even  the  crude  laws  of  the  Mosaic 
Code,  and  attributed  their  condition  to  the  visitation  of 
the  devil,  or  the  wrath  of  an  offended  deity.    But  medi- 

26 


MODERN    MEDICINE 


cal  men  have  ever  labored  to  discover  the  cause  of  disease, 
and  the  means  to  prevent  its  occurence.  With  an  aUruism 
rarely  approached  in  other  professions  the  physicians  of 
of  the  past  and  the  present  have  given  unceasingly  of 
their  time  and  labor  to  destroy  the  very  source  of  their 
living. 

Time  will  not  permit  a  record  here  of  the  victories 
that  have  been  achieved  in  preventive  medicines,  begin- 
ning with  small-pox  and  now  approaching  a  successful 
issue  in  the  case  of  yellow  fever,  malaria,  typhoid  and 
other  diseases.  The  recent  completion  of  the  Panama 
Canal,  a  task  rendered  possible  only  by  the  sanitary  regu- 
lation promulgated  and  enforced  by  the  distinguished 
member  of  this  association,  Surgeon-General  Gorgas, 
stands  as  an  unquestioned  tribute  and  enduring  monu- 
ment to  the  perfection  and  efficiency  of  the  measures 
which  modern  science  has  developed  for  the  maintenance 
of  health  and  the  prevention  of  disease. 

The  public  Health  Service  is  now  recognized  as  one 
of  the  most  important  departments  of  our  general  and 
local  government.  The  work  in  this  service  offers  the 
present  day  graduate  one  of  the  most  attractive  fields 
open  to  him.  It  does  not  hold  out  the  promise  of  fortune 
that  goes  with  rare  eminence  in  private  practice,  but  it 
guarantees  to  every  worker  a  reasonable  income,  the  op- 
portunity for  scientific  study  and  research,  the  certainty 
of  performing  a  useful  service  for  his  community,  and 
the  possibility  of  becoming  a  great  benefactor  to  the 
human  race. 

The  state  and  local  health  boards  are  securing  the 
service  of  an  increasing  number  of  the  best  men  of  the 
profession  who  are  devoting  their  time  and  energies,  not 

27 


THE  PROFIT  AND  LOSS  ACCOUNT  OF 

only  to  sanitation  and  preventive  medicine,  but  also  to 
an  educational  campaign  to  arouse  the  profession  to  a 
sense  of  its  duty  as  guardian  of  the  public  health,  and 
to  acquaint  the  laity  w^ith  a  knowledge  of  the  cause  and 
means  of  preventing  disease.  The  attendance  of  these 
trained  workers  and  practiced  speakers  at  the  meetings 
of  our  county  and  state  medical  societies  has  already  had 
the  effect  of  raising  the  value  of  the  papers  read,  and  of 
making  the  discussions  more  interesting  and  scientific. 

Public  health  work  marked  the  beginning  of  a  new 
era  in  the  relations  between  the  profession  and  the  public. 
It  was  characterized  by  an  effort  on  the  part  of  the  pro- 
fession to  take  the  public  into  its  confidence.  Its  purpose 
was  to  make  the  people  a  partner  in  the  conservation  of 
health.  A  short  time  ago  if  a  doctor  addressed  a  lay 
audience  on  a  medical  subject,  his  motives  were  ques- 
tioned. Now  the  profession  employs  every  agency  of 
publicity  to  spread  the  propaganda  against  disease.  The 
columns  of  the  newspapers  and  magazines,  the  walls  of 
public  conveyances,  the  lecture  platform,  the  pulpit,  the 
school  and  the  drama  warn  and  plead  against  the  danger 
of  the  mosquito  and  house-fly,  the  communicability  of 
tuberculosis,  the  insidiousness  of  cancer,  and  the  pathos  of 
"Damaged  Goods." 

Publicity  in  medical  matters  has  undoubtedly  done 
good,  but  it  has  also  done  harm,  and  here  as  elsewhere 
we  must  record  not  only  the  profit  but  the  loss. 

The  first  loss  is  seen  in  the  schools,  for  an  examination 
of  the  text-books  employed  in  physiology  and  hygiene 
will  show  that  just  as  at  one  time  the  children  of  the  South 
were  taught  false  history,  so  now  they  are  often  taught 
false  science.     Investigation  will  show  that  these  text- 

28 


MODERN    MEDICINE 


books  are  prepared  by  literary  hacks  employed  by  fanati- 
cal associations  to  impress  their  views  on  various  sub- 
jects, especially  with  reference  to  the  action  of  alcohol. 
No  one  questions  the  evil  of  the  abuse  of  this  drug,  but 
neither  the  cause  of  temperance  nor  of  science  is  advanced 
by  untruthful  statements  or  manufactured  statistics. 
Another  evil  in  the  schools  is  the  attempt  to  teach  sex 
hygiene.  It  is  a  difficult  question  to  decide  in  an  indi- 
vidual case  when  and  how  to  impart  this  delicate  infor- 
mation. If  parents  hesitate  to  discuss  the  matter  with 
their  child  at  home,  it  is  certainly  an  evasion  of  responsi- 
bility attended  by  great  danger  to  turn  the  subject  over 
to  an  old  maid  teacher  to  deal  with  in  a  mixed  school. 

The  second  loss  from  the  general  information  given 
the  laity  on  medical  subjects  is  seen  in  its  effect  on  women. 
Matters  are  now  discussed  in  a  mixed  audience  with  a 
freedom  and  frankness  that  would  have  been  thought  un- 
believable a  generation  ago.  Beginning  with  co-education 
and  equal  suffrage,  subjects  suggestive  of  sex  differences, 
the  field  of  activity  of  the  female  mind  has  broadened, 
until  now  the  average  high-school  girl  is  more  or  less 
familiar  with  the  problems  embraced  under  the  terms 
eugenics,  race  suicide,  the  social  evil,  the  age  of  consent, 
the  white  slave  traffic  and  the  regulation  of  the  red  light 
district. 

The  woman  of  today  has  lost  her  prudery.  Let  her 
bew^are  lest  she  lose  her  modesty  as  well !  If  such  should 
prove  the  case  it  would  be  necessary  to  change  from  the 
credit  to  the  debit  side,  the  balance  now  found  in  "The 
Profit  and  Loss  Account  of  Modern  Medicine." 


29 


Latent  and  Active  Neurasthenia  in  Its 
Relation  to  Surgery  * 

We  have  met  at  this  the  twenty-second  annual  session 
of  the  Southern  Surgical  and  Gynecological  Association, 
some  to  learn,  some  to  teach,  and  all  to  secure  a  well- 
earned  vacation,  and  for  a  time,  at  least,  be  free  from  the 
complaints  of  nervous  and  exacting  patients.  This  being 
the  case,  some  of  you  may  think  that  in  choosing  as  the 
subject  for  a  presidential  address,  "Latent  and  Active 
Neurasthenia  in  its  Relation  to  Surgery,"  I  have  shown 
a  lack  of  tact  by  introducing  a  topic  which  brings  to 
mind  unpleasant  experiences,  which  for  the  occasion  you 
wish  to  forget.  I  trust  this  will  not  be  the  case,  and  hope 
there  will  be  found,  if  not  in  what  I  write,  at  least  in 
what  you  read  between  the  lines,  something  which  will 
be  of  practical  value. 

Specialists  usually  divide  functional  neurotic  disorders 
into  hysteria,  neurasthenia,  and  hypochondria. 

Hysteria  is  a  spec-al  psychical  state  often  produced  in 
certain  individuals  by  suggestion,  and  capable  of  being 
relieved  by  persuasion.  It  is  a  condition  of  nervous  insta- 
bility, stigmatized  by  emotional  storms,  crises,  contrac- 
tures, and  paralyses,  by  a  craving  for  sympathy,  a  desire 
for  an  audience,  and  a  tendency  to  pose. 

Neurasthenia  is  a  fatigue  neurosis  due  in  part  to  mal- 
nutrition, and  in  part  to  functional  overexertion,  occur- 


*  Address  at  the  meeting  of  the  Southern  Surgical  and  Gyne- 
cological Association,  Hot  Springs,  Virginia,  December,  190Q. 

31 


LATENT   AND   ACTIVE   NEURASTHENIA 

ring  in  persons  with  an  hereditary  or  acquired  predispo- 
sition. It  is  characterized  by  exhaustibiHty  of  the  nervous 
system,  sHght  exertion  causing  prostration  and  bringing 
on  the  various  distressing  symptoms  from  which  the 
patient  suffers. 

Hypochondria  is  a  mental  disease  marked  by  obses- 
sions, depressions,  and  morbid  fears  concerning  the 
heahh  of  the  individual.  It  is  not  very  common,  is  easily 
diagnosticated,  and  is  usually  incurable. 

Hysterical  patients  give  a  great  deal  of  trouble  before 
an  operation,  but  do  very  well  after  the  ordeal  is  over. 
A  nervous  woman  who  describes  her  symptoms  with 
hesitating  vivacity,  who  desires  to  discuss  every  detail  of 
her  operation  and  subsequent  treatment,  and  who  is  pos- 
sessed of  exaggerated  fears  of  complications  which  may 
develop,  or  of  the  ultimate  result  which  may  follow, 
usually,  after  the  operation  is  over,  becomes  a  model 
patient.  Her  imagination  enters  upon  fresh  fields;  she 
becomes  hopeful  and  courageous,  and  begins  at  once  to 
plan  a  new  life  of  activity. 

Neurasthenic  patients  usually  discuss  their  cases  calmly 
and  logically:  they  describe  their  symptoms  systemati- 
cally, and  employ  technical  terms  correctly.  They  com- 
plain of  nearly  every  organ  in  the  body.  The  essential 
feature  of  their  clinical  picture  is  fatigue,  exhaustion,  and 
incapacity  for  prolonged  physical  or  mental  exertion. 
They  suffer  from  general  weakness,  headache,  backache, 
and  insomnia.  Their  mental  condition  is  one  of  hesita- 
tion, doubt,  and  indecision.  They  do  not  reach  conclu- 
sions, and  are  unable  to  fix  their  attention  for  any  period 
of  time.  They  usually  have  digestive  and  sexual  dis- 
orders, and  often  grossly  exaggerate  the  importance  of 

32 


IN  ITS  RELATION  TO  SURGERY 

their  symptoms.  They  frequently  have  psychic  depres- 
sions, shown  by  irritabiHty,  introspection  and  selfishness. 
They  are  firmly  convinced  as  to  the  nature  of  their  di- 
sease, and  come  to  the  surgeon  for  what  they  believe  to 
be  a  necessary  operation. 

Hypochondriac  patients  are  the  victims  of  what  is  often 
a  hopeless  psychosis.  The  individual  is  possessed  of  the 
idea  that  she  has  some  strange  and  horrible  malady.  She 
soon  wears  out  the  patience  of  her  family  and  friends, 
and  in  order  to  secure  a  sympathetic  listener,  and  to 
demonstrate  to  the  community  the  serious  nature  of  her 
disease,  she  goes  from  surgeon  to  surgeon,  and  from 
hospital  to  hospital,  offering  herself  as  a  bloody  sacrifice 
to  her  curious  obsession,  and  glorying  in  her  martyrdom. 

As  simple  hysteria  is  easily  recognized  and  controlled, 
and  as  pure  hypochondria  is  usually  unmistakable  and 
incurable,  I  will  dismiss  these  two  subjects  and  devote 
the  time  at  my  disposal  to  neurasthenia.  I  shall  not  limit 
the  term  to  the  definition  given  by  the  scientific  neurolo- 
gist, but  shall  employ  it  in  the  broad  sense  in  which  it  is 
used  by  the  practical  surgeon.  This  is  necessary  because, 
while  in  theory  it  is  easy  to  distinguish  between  hysteria, 
neurasthenia,  and  hypochondria,  in  practice  it  will  be 
found  that  the  symptoms  of  two  or  more  of  them  are 
often  present  in  the  same  patient  at  the  same  time.  Thus, 
one  writer  says  all  hysterical  patients  are  neurasthenic, 
but  all  neurasthenics  are  not  hysterical.  Name  and 
classify  neuroses  as  you  please,  the  trail  of  the  serpent 
is  over  them  all. 

None  of  us  want  neurasthenics  as  patients,  but  all  of 
us  have  them  constantly  in  our  practice.  Some  of  them 
are  referred  to  us  by  the  general  practitioner ;  some  come 

33 


LATENT   AND   ACTIVE    NEURASTHENIA 

to  us  from  other  specialists ;  and  some  develop  their  per- 
nicious symptoms  under  our  personal  observation  and 
treatment.  In  deploring  the  frequency  of  neurasthenia, 
and  in  criticising  practitioners  in  other  departments  of 
medicine  for  the  occurrence  of  the  disease,  it  should  be 
remembered  that  we,  as  surgeons,  are  responsible  for  the 
development  of  a  large  number  of  these  cases.  A  surgical 
operation  injudiciously  performed,  or  carried  out  without 
proper  precautions  on  a  susceptible  patient,  will  fre- 
quently be  the  beginning  of  a  neurosis,  and  terminate  in 
the  condition  known  as  traumatic  or  surgical  neuras- 
thenia. 

It  is  the  object  of  this  address,  first,  to  emphasize  the 
importance  of  refusing  to  operate  on  a  neurasthenic 
patient  unless  the  symptoms  can  be  clearly  shown  to  be 
due  to  organic  disease ;  and  second,  to  impress  the  neces- 
sity, if  an  operation  is  undertaken  on  a  patient  with  either 
latent  or  developed  neurasthenia,  to  protect  the  nervous 
system  from  psychical  and  physical  shock,  not  only  by  a 
proper  preliminary  preparation,  but  by  careful  and  often 
prolonged  post-operative  and  post-hospital  treatment. 

A  surgeon  cannot  be  expected  to  be  an  expert  neurolo- 
gist, but  for  his  own  happiness,  if  not  for  his  patient's 
welfare,  he  must  study  functional  neurotic  disorders,  as 
well  as  organic  diseases.  He  must  learn  to  know  his  limi- 
tations, as  well  as  recognize  his  abilities ;  and  to  estimate 
the  possible  injurious  effects  as  well  as  the  probable  bene- 
ficial results  to  be  expected  from  surgical  intervention. 
He  must  remember  that  the  patient  does  not  come  to  him 
primarily  to  be  cut,  but  to  be  cured ;  and  that  an  operation 
is  not  a  success  unless  the  individual  is  restored  to  health, 
not  only  physically,  but  also  psychically;  not  only  anato- 

34 


IM  ITS  RELATION  TO  SURGERY 


mically,  but  also  symptomatically.  In  surgery  the  main 
question  is  no  longer  one  of  mortality,  but  one  of  mor- 
bidity. In  endeavoring  to  forecast  the  end  results  of  an 
operation,  the  mental  and  nervous  condition  of  the  patient 
must  be  carefully  considered.  If  neuroses  exist,  without 
anatomical  disease,  an  operation  will  do  no  good,  and  may 
result  in  harm.  If  neuroses  are  found  coincident  with 
pathological  lesions,  an  operation  may  prove  of  great 
benefit;  but  in  relieving  the  physical  disease,  care  must 
be  taken  to  avoid  increasing  the  nervous  disorder.  If 
neuroses  are  present,  reflex  in  character  and  due  to  rem- 
ediable causes,  an  operation  may  be  undertaken  with 
assurance  of  complete  success.  In  other  words,  the  sur- 
geon should  divide  these  cases  into  three  classes :  the  first 
to  be  avoided ;  the  second  to  be  undertaken  with  caution ; 
and  the  third  to  be  cheerfully  given  the  relief  to  which 
they  are  entitled. 

Of  the  class  to  be  avoided,  because  the  neurasthenia 
has  no  organic  basis,  Goodell  says :  "The  sufferer  may 
be  a  jilted  maiden,  a  bereaved  mother,  a  grieving  widow, 
or  a  neglected  wife,  and  all  her  uterine  symptoms — yes, 
every  one  of  them — may  be  the  outcome  of  her  sorrow, 
and  not  of  her  local  lesions.  She  is  suffering  from  a  sore 
brain  and  not  from  a  sore  womb."  Here  an  operation 
will  not  relieve,  but  will  aggravate,  the  symptoms. 

Of  the  class  to  be  undertaken  with  caution,  because  the 
neurasthenia  is  merely  coincident  with  anatomical  disease, 
it  is  often  a  question  whether  the  patient  had  better  en- 
dure the  evils  he  has,  or  fly  to  those  he  knows  not  of. 
An  illustration  of  where  one  of  our  greatest  surgical 
philosophers  elected  the  first  course  is  quoted  from  Mum- 
ford's  recent  article:     ''Said  John  Hunter  to  a  patient 

35 


LATENT   AND   ACTIVE   NEURASTHENIA 

with  a  chronic  running  sore  who  was  brought  to  him  for 
consultation:  'And  so,  sir,  you  have  a  chronic  running 
sore  ?' 

"'Yes,  Mr.  Hunter/ 

"  'Well,  sir,  if  I  had  your  chronic  running  sore,  I  should 
say,  "Mr.  Sore,  you  may  run  and  be  damned."  '  " 

In  other  cases  it  may  be  deemed  best  to  operate — not 
to  cure  the  neurasthenia,  but  to  relieve  the  pathological 
condition.  Great  care  must  be  exercised  to  avoid  increas- 
ing the  nervous  weakness  by  the  very  means  used  to  cure 
the  physical  discomfort.  This  is  especially  true  in  patients 
who  have  been  previously  the  subject  of  other  opera- 
tions. 

Of  the  class  where  the  neurasthenia  is  directly  due  to 
anatomical  disease,  it  may  be  said  that  if  the  diagnosis 
can  be  made  and  the  cause  removed,  the  patient  will  be 
cured.  Often  the  symptoms  are  obscure  and  misleading, 
and  much  patient  investigation  will  be  necessary  to  reach 
the  proper  conclusion.  A  distinguished  modern  surgeon 
relates  the  following  experience  occurring  in  his  early 
professional  life.  One  of  his  friends  developed  digestive 
disturbances  and  came  to  see  him  with  periodical  regu- 
larity. He  first  treated  him  along  accepted  lines ;  then 
gave  him  all  the  samples  of  proprietary  medicine  left  at 
his  office,  and  as  he  did  not  improve,  he  decided  that  the 
man  was  a  neurasthenic.  One  day  he  was  hurriedly 
called  to  see  him,  and  found  that  he  had  acute  appendi- 
citis. He  operated  on  him,  and  hoped  that  by  taking  out 
the  appendix  he  had  not  only  relieved  the  immediate 
danger,  but  had  also  removed  the  cause  of  his  previous 
symptoms.  Much  to  his  disappointment,  the  patient,  after 
leaving  the  hospital,  complained  as  before,  and  he  was 

36 


IN  ITS  RELATION  TO  SURGERY 

therefore  confirmed  in  his  opinion  that  he  was  a  neuras- 
thenic. Later,  the  patient  developed  jaundice  and  symp- 
toms of  cholecystitis.  He  was  operated  on  a  second  time 
and  a  number  of  gallstones  removed,  and  it  was  again 
hoped  that  the  cause  of  his  trouble  had  been  diagnosti- 
cated and  relieved.  Before  he  left  the  hospital,  however, 
he  began  to  have  his  old  pains,  and  then  the  surgeon  said 
he  knew  he  was  a  neurasthenic.  Despite  his  failure  to  se- 
cure relief,  the  patient  persisted  in  coming  to  the  office, 
and  one  day  called  just  after  the  installation  of  an  x-ray 
apparatus.  More  to  test  the  new  instrument  than  with  any 
expectation  of  benefiting  the  patient,  a  skiagraph  was 
made  of  his  abdomen,  and  it  was  found  that  he  had  a 
stone  in  his  right  kidney.  A  third  operation  was  per- 
formed, the  stone  removed,  and  from  that  time  to  this 
the  patient  has  been  absolutely  well.  This  is  not  a  unique 
case.  All  of  us  have  had  similar,  if  not  quite  such  aggra- 
vated, experiences.  The  story  is  told  to  impress  the  fact 
that  even  an  apparently  hopeless  neurasthenic  should  not 
be  condemned  without  a  trial,  as  some  of  them  may  be 
cured  provided  a  correct  diagnosis  is  made. 

The  means  employed  by  surgeons  to  distinguish  be- 
tween hopeless  and  curable  neurasthenia  cover  the  entire 
field  of  diagnostic  medicine,  and  cannot  be  discussed.  The 
precautions  to  be  observed  in  operating  on  a  patient  who 
is  likely  to  develop  neurasthenia  will  now  be  considered. 

Two  separate  and  independent  preliminary  examina- 
tions should  be  made  of  every  surgical  patient :  the  first 
for  the  purpose  of  diagnosis,  or  the  determination  of  the 
condition  to  be  corrected;  the  second  for  the  purpose  of 
prognosis,  or  the  determination  of  the  safety  of  the  opera- 
tion, and  the  probability  of   a  complete   cure  resulting 


LATENT   AND   ACTIVE   NEURASTHENIA 

from  it.  To  do  this  satisfactorily  it  will  usually  be  found 
necessary  to  secure  the  aid  and  cooperation  of  several 
specialists.  Few  busy  surgeons  have  the  time  or  skill 
to  make  the  necessary  physical  examination  of  the  heart 
and  lungs,  or  the  laboratory  investigation  of  the  urine, 
blood,  and  stomach  contents,  to  say  nothing  of  the  special 
work  which  is  sometimes  required  of  the  bacteriologist, 
ophthalmologist,  neurologist,  rontgenologist,  and  other 
experts.  Patients  will  not  object  to  frequent  and  pro- 
longed examinations,  but  will  be  inspired  with  confidence 
in  the  surgeon  by  the  realization  that  nothing  is  taken 
for  granted,  and  that  every  effort  is  being  employed  to 
ascertain  the  nature  of  their  trouble  and  the  best  method 
to  effect  a  cure.  In  fact,  the  laity  are  now  so  educated 
in  medical  matters  that  failure  to  give  a  case  a  thorough 
preliminary  examination  is  a  cause  for  criticism  and 
distrust. 

An  important  exception  to  this,  however,  is  in  the 
case  of  a  young,  unmarried  woman  who  complains  of 
pelvic  symptoms.  She  may  be  of  neurotic  temperament, 
and,  owing  to  backache  and  painful  menstruation,  become 
convinced  she  has  uterine  or  ovarian  disease,  when,  in 
fact,  she  has  no  local  trouble.  On  the  other  hand,  she 
may  have  cervical  stenosis,  uterine  displacement,  or 
ovarian  cystoma.  In  such  a  case  a  physical  examination 
should  be  made  to  ascertain  whether  the  trouble  is  neuro- 
logical or  gynecological.  In  order  to  minimize  the  psychi- 
cal shock  and  to  avoid  physical  pain,  the  examination 
should  be  made  under  a  general  anesthetic.  If  her  symp- 
toms are  found  to  be  due  to  some  defect  of  her  nervous 
system,  she  should  be  positively  assured  she  has  no  local 
lesion,  and  be  referred  to  a  suitable  attendant  for  general 

38 


IN  ITS  RELATION  TO  SURGERY 

treatment.  If,  on  the  other  hand,  her  symptoms  are 
found  to  be  due  to  actual  disease  of  the  pelvis,  she  should 
be  given  the  surgical  relief  her  case  demands.  Noble  has 
emphasized  the  fact  that  virgins  rarely  suffer  from  trau- 
matism and  infection  of  the  genital  organs,  and  when 
pathological  disease  exists  they  almost  invariably  demand 
operative  treatment.  Repeated  examinations,  local  appli- 
cations, and  other  manipulations  do  them  little  good,  and 
often  convert  them  into  chronic  nervous  invalids.  The 
"pelvic  woman"  of  the  old  author  is  the  ''sexual  neuras- 
thenic" of  the  modern  writer. 

The  preparation  of  a  patient  for  operation  should  be 
both  physical  and  psychical.  In  the  past  much  attention 
has  been  paid  to  the  first,  and  but  little  to  the  second. 
We  now  recognize  that  we  have  overdone  starvation,  pur- 
gation, and  sterilization,  and  have  neglected  to  study  the 
patient's  mental  attitude  to  the  operation,  in  order  to 
lessen  apprehension,  if  it  is  unduly  present;  to  inspire 
confidence,  if  it  is  lacking;  and  to  lay  the  foundation  for 
a  philosophy  which  will  be  needed  during  convalescence. 

The  surgeon's  first  efforts  should  be  directed  to  reliev- 
ing the  patient's  dread  of  going  to  the  hospital.  The  laity 
are  being  rapidly  educated  to  a  just  appreciation  of  the 
advantages  afforded  by  such  institutions,  but  some  people 
still  regard  them  as  a  cross  between  a  prison  and  a  pest 
house.  The  easiest  and  most  effective  way  to  overcome 
this  belief  is  to  induce  the  patient  to  enter  the  hospital 
several  days  before  the  date  fixed  for  the  operation.  In 
the  environment  of  a  well  regulated  sanatorium  excite- 
ment and  fear  will  soon  be  replaced  by  calmness  and  hope. 

The  surgeon  should  see  the  patient  daily.  His  bearing 
should  be  kindly  but  not  oversympathetic.     The  patient 

39 


LATENT  AND   ACTIVE   NEURASTHENIA 

should  not  be  the  object  of  commiseration  because  of  the 
anticipated  operation,  but  the  subject  of  congratulation 
because  her  case  is  one  that  can  be  cured  by  surgery. 
She  should  be  made  to  realize  that  operations  are  but  an 
incident  in  the  day's  work,  and  that,  while  her  case  will 
receive  all  needful  attention,  she  is  not  the  most  important 
individual  in  the  hospital.  Care  should  be  taken,  in  talk- 
ing to  her,  not  to  magnify  the  importance  of  her  lesions 
or  the  difficulty  and  danger  incident  to  their  correction. 
The  relatives  and  friends  should,  of  course,  be  informed 
of  the  facts  in  the  case,  but  the  patient  should  not  be 
burdened  with  doubts  and  fears.  It  is  also  well  to  avoid 
giving  unnecessary  information  about  the  etiology  and 
pathology  of  her  disease,  or  to  describe  the  different 
methods  by  which  her  abnormality  might  be  corrected. 
While  she  will  listen  eagerly  to  any  statement  with  refer- 
ence to  her  case,  and  will  enter  into  a  discussion  of  what 
is  best  to  do  for  her,  she  realizes  that  she  does  not  fully 
comprehend  what  has  been  said  to  her  by  the  surgeon, 
and  is  worried  by  the  responsibility  she  has  assumed  in 
the  opinion  she  has  expressed  to  him. 

It  is,  however,  important  at  this  time  that  the  surgeon 
warn  the  patient  against  certain  symptoms,  complications, 
and  sequelae  which  may  develop  after  the  operation,  tell- 
ing her  that  while  they  entail  no  danger  and  will  not 
effect  the  final  result,  it  is  well  that  she  should  realize 
their  possibility,  in  order  that,  if  they  develop,  she  may 
know  they  were  foreseen.  For  instance,  a  patient  to  be 
operated  on  for  hemorrhoids  should  be  told  that  possibly 
she  will  require  catheterization  for  a  day  or  two ;  a  patient 
with  a  goitre,  that  her  throat  will  feel  sore,  and  it  will 
hurt  her  to  swallow;  a  patient  with  gallstones,  that  a 

40 


IN  ITS  RELATION  TO  SURGERY 

drain  will  be  used  for  a  week  or  ten  days ;  and  a  patient 
with  fibromyoma  of  the  uterus,  that  artificial  menopause 
will  follow,  with  symptoms  such  as  usually  occur  at  the 
''change  of  life."  A  word  of  warning  before  the  opera- 
tion will  be  found  to  be  worth  more  than  an  hour's 
explanation  afterward  to  prevent  discouragement  from 
ordinary  sequelae,  whose  significance  and  importance  are 
not  understood. 

Finally,  the  patient's  fear  of  the  anesthetic  should  be 
relieved  by  reassurance,  reason,  or  ridicule.  A  badly 
frightened  patient  should  never  be  sent  to  the  operating 
room.  Psychical  shock  is  a  greater  factor  than  traumatic 
shock  in  the  production  of  surgical  neurasthenia. 

Some  patients  are  in  good  nervous  and  physical  condi- 
tion and  require  practically  nothing  but  the  mechanical 
correction  of  a  local  trouble.  Others  are  as  bad  off  ner- 
vously as  they  are  physically,  and  often  will  be  more  bene- 
fited by  a  modified  form  of  rest  cure  than  by  the  operation 
itself.  Most  surgeons  recognize  this  fact,  but  are  often 
unable  to  carry  out  the  principles  of  seclusion,  rest,  full 
feeding,  bathing,  massage,  and  electricity,  as  taught  by 
Mitchell,  because  of  the  present  attitude  of  the  public  to 
surgery.  Not  many  years  ago  an  operation  was  consid- 
ered, in  the  words  of  the  marriage  ceremony,  as  something 
not  to  be  entered  into  unadvisedly  or  lightly,  but  discreet- 
ly, soberly,  and  in  the  fear  of  God.  Today  it  has  come 
to  be  regarded  as  a  comparatively  trivial  event,  and  the 
principal  dread  is  the  surgeons  fee.  In  the  old  days  it  was 
understood  that  a  patient  requiring  a  serious  operation 
would  have  to  remain  two  or  three  months  in  a  hospital. 
At  present  patients  enter  the  hospital  one  day,  are  oper- 
ated upon  the  next,  begin  to  ask  when  they  can  go  home 

41 


LATENT   AND   ACTIVE   NEURASTHENIA 

before  they  stop  vomiting,  and  usually  are  permitted  to 
leave  before  it  is  wise  for  them  to  do  so. 

Nearly  all  surgeons  admit  the  injurious  results  which 
frequently  follow  the  premature  discharge  of  a  case  from 
the  hospital,  but  most  of  them  try  to  evade  responsibility 
by  attributing  the  evil  to  the  unreasonable  insistence  of 
the  patient  to  be  permitted  to  return  home.  The  fault, 
however,  is  not  with  the  laity,  but  with  the  profession. 
Patients  would  consent  to  longer  detention  in  the  hospital 
just  as  submissively  today  as  they  did  some  years  ago, 
if  they  believed  it  to  be  necessary.  The  fault  is  with  a 
few  surgeons  who,  for  various  reasons,  have  entered  into 
a  competition  to  see  who  can  get  their  cases  out  quickest, 
and  have  thereby  set  a  precedent  which  others  have  fol- 
lowed. Some  have  been  actuated  by  a  desire  to  save  the 
patient  time  and  money ;  others  by  a  desire  to  advertise 
themselves.  The  public  is  prone  to  estimate  the  ability 
of  a  surgeon  by  the  apparent  rapidity  of  the  recovery  of 
his  patients,  and  to  make  comparisons  between  different 
operators  on  the  basis  of  the  length  of  time  they  keep 
their  patients  in  the  hospital.  This  is  not  surprising,  as 
even  some  of  the  profession  do  not  seem  fully  to  realize 
that,  all  things  being  equal,  a  wound  will  not  heal  quicker 
for  one  man  than  it  will  for  another,  and  the  number  of 
days  a  surgeon  keeps  the  patient  in  bed  is  not  a  measure 
of  his  surgical  dexterity,  but  of  his  surgical  judgment. 

In  order  to  appreciate  the  dangers  to  a  patient  of  pre- 
mature discharge,  it  is  necessary  to  contrast  the  condi- 
tions of  hospital  and  home  life.  The  change  is  as  decided 
and  the  influence  as  great  to  either  sex,  the  man  on  return- 
ing home  being  confronted  by  financial  obligations  and 

42 


IN  ITS  RELATION  TO  SURGERY 

business  complications,  and  the  woman  by  family  cares 
and  domestic  duties. 

By  way  of  illustration,  we  will  take  the  case  of  a 
woman.  While  in  the  hospital  she  is  free  from  responsi- 
bility, and  has  comforts  and  conveniences  which  are  often 
as  new  as  they  are  delightful.  Her  room  is  clean  and 
well  heated ;  dainty  meals  are  served  with  clock-like 
regularity;  and  an  electric  bell  commands  the  services 
of  an  attractive  and  efficient  nurse.  Other  patients  recov- 
ering from  more  serious  operations  inspire  her  with 
courage,  and  she  emulates  their  example  and  tries  to 
surpass  them'  in  rapidity  of  progress.  It  is  like  playing 
a  game  to  see  who  can  get  well  first.  Above  all,  she  is 
conscious  of  being  under  the  watchful  eye  of  the  surgeon, 
and  appreciates  the  fact  that  complications,  if  they  occur, 
will  be  promptly  corrected. 

Now  compare  the  condition  of  this  woman  when  she 
returns  home.  At  the  very  outset  she  has  to  meet  either 
injudicious  sympathy  or  unreasonable  expectations. 
Sometimes  her  friends  and  relatives,  by  a  combination 
of  commiseration  and  indulgence,  induce  her  to  believe 
that  she  has  been  the  most  unfortunate  woman  on  earth, 
and  is  therefore  entitled  to  lead  a  life  of  invalidism  for 
the  remainder  of  her  existence.  Or,  again,  her  husband 
and  family  may  show  in  their  manner,  if  they  do  not 
express  it  in  words,  the  conviction  that  she  ought  to  be 
in  good  working  order  after  so  much  money  has  been 
spent  in  repairing  her,  and,  as  a  result,  she  feels  impelled 
to  exert  herself  to  discharge  duties  for  which  she  is  not 
physically  competent.  During  the  woman's  absence  from 
home  the  domestic  economy  often  gets  sadly  out  of  gear. 
Undesirable  relatives  have  come  to  make  visits ;  servants 

43 


LATENT  AND   ACTIVE   NEURASTHENIA 

have  grown  slack  and  impudent;  children  have  been 
spoiled  and  pampered ;  and  the  husband's  sexuel  appetite 
has  not  been  gratified.  As  a  consequence,  in  the  first 
few  days  after  her  return,  she  has  to  snub  her  mother-in- 
law,  discharge  her  servants,  clean  her  house,  cooik  her 
dinner,  spank  her  babies,  and  resist  or  yield  to  her 
husband's  advances. 

If  she  lives  in  the  country,  as  is  often  the  case,  the 
contrast  between  hospital  and  home  life  is  even  greater. 
The  house  is  often  inadequately  heated ;  servants  are  gen- 
erally unreliable  and  incompetent;  food  is  usually  indi- 
gestible in  character  and  monotonous  in  variety ;  outdoor 
exercise  is  difficult  to  practice;  a  bath  can  only  be  obtained 
by  bringing  in  a  wash-tub  and  heating  water  in  a  kettle; 
and  an  evacuation  of  the  bowels  can  only  be  effected  by 
an  excursion  to  the  garden,  along  a  grass-grown  path 
overhung  with  boxwood  bushes,  and  by  the  exposure  of 
a  vulnerable  portion  of  the  anatomy  to  the  chilling  wintry 
blasts.  Is  it  a  wonder  that  the  woman  becomes  neuras- 
thenic and  fails  to  get  well  ? 

What  has  been  said  with  reference  to  the  short  stay  of 
patients  in  the  hospital,  and  the  conditions  which  fre- 
quently exist  at  home  work  adversely  to  their  recovery, 
makes  it  plain  that  those  interested  in  their  welfare  should 
thoughtfully  consider  the  situation  and  endeavor  to 
remove  the  evil.  The  remedy  obviously  consists  in  the 
patient's  remaining  longer  under  the  care  of  the  surgeon, 
and  on  returning  home  being  placed  under  the  close 
supervision  of  the  family  physician. 

A  patient  should  not  be  detained  an  unnecessary  time 
in  the  hospital,  as  it  is  not  only  a  waste  of  the  individual's 
time    and    money,    but    also    tends    to   the    creation    of 

44 


IN  ITS  RELATION  TO  SURGERY 

invalidism.  A  patient  should  not  be  dismissed  too  soon, 
as  failure  to  secure  the  expected  benefit  from  the  opera- 
tion may  lead  to  discouragement,  which  finally  results  in 
well-established  neurasthenia.  Convalescence  is  a  ques- 
tion of  temperament,  and  must  be  psychical  as  well  as 
physical.  People  are  coming  to  regard  surgeons  as 
mechanics,  and  patients  as  machines  which  are  to  be  re- 
paired. They  must  be  taught  that  the  operation  is  not 
everything,  and  that  the  after-treatment  is  often  of  equal 
importance.  They  must  be  made  to  understand  that  the 
operation  merely  corrects  an  abnormal  condition  and  puts 
Nature  in  a  position  to  effect  a  cure ;  that  often  the  first 
effect  of  an  operation  is  injurious,  and  that  the  beneficial 
results  are  only  experienced  after  the  system  recovers 
from  the  shock  and  readjusts  itself  to  new  conditions; 
that  sometimes  it  takes  weeks,  months,  or  even  years  for 
this  to  be  accomplished.  They  must  be  impressed  with 
the  fact  that  surgical  patients  are  not  well  because  their 
wounds  have  healed,  but  should  remain  in  the  hospital 
until  they  have  regained  to  a  certain  extent  their  physical 
strength  and  nervous  equilibrium,  and  that,  after  return- 
ing home,  for  a  time  they  should  lead  a  life  of  prudence 
and  restraint. 

The  surgeon  usually  attempts  to  direct  the  treatment 
of  patients  after  they  return  home  by  giving  them  verbal 
instruction  when  they  leave  the  hospital,  and  by  subse- 
quently corresponding  w4th  them,  but  the  end  desired 
can  be  more  effectually  and  properly  secured  by  referring 
the  patient  back  to  the  family  physician.  The  reason 
verbal  instructions  are  not  satisfactory  is  because  they 
cannot  cover  all  eventualities,  and  are  frequently  not 
understood.     When  a   surgeon  takes  charge  of  a  new 

45 


LATENT  AND   ACTIVE   NEURASTHENIA 

case  he  is  on  his  mettle  both  to  make  a  good  impression 
and  to  solve  the  diagnostic  problems  presented.  Con- 
sultations are  usually  held  with  other  members  of  the 
staff,  and  for  a  day,  at  least,  the  case  receives  more 
attention  than  any  other  patient  in  the  hospital.  The 
diagnosis  made,  the  operation  performed,  the  danger 
period  passed,  and  convalescence  established,  it  is  only 
natural  that  the  surgeon's  time  and  thoughts  are  occupied 
with  more  recent  cases,  so  when  the  time  comes  to  say 
good-bye  and  give  parting  instructions,  he  simply  utters 
a  few  perfunctory  injunctions,  tells  her  to  be  patient  and 
prudent,  and  to  write  him  if  she  has  any  untoward  symp- 
toms. The  patient's  expectation  and  disappointment  are 
often  apparent,  but  she  hesitates  to  ask  the  many  ques- 
tions which  are  uppermost  in  her  mind  for  fear  of  weary- 
ing or  irritating  the  busy  man,  the  value  of  whose  time 
she  has  been  taught  to  respect. 

The  reason  subsequent  treatment  by  mail  is  not  satis- 
factory is  because  patients  usually  fail  to  give  important 
facts,  and  either  exaggerate  or  underestimate  their  symp- 
toms. Also,  because  the  surgeon  cannot  remember  their 
idiosyncrasies  and  peculiarities,  and  even  if  he  prescribes 
correctly,  his  advice  lacks  the  personal  element  of  sug- 
gestion which  is  so  essential  to  make  it  efficient. 

How  much  better  it  would  be  if  the  patient  were  ex- 
amined before  she  left  the  hospital,  and  told  that  the 
operation  which  had  been  performed  had  satisfactorily 
corrected  the  condition  which  had  given  rise  to  her 
symptoms,  but  that  she  was  not  well  and  that  it  would 
require  some  months  of  proper  living  to  restore  her  to 
full  health  and  activity.  She  should  be  directed,  on 
returning  home,  to  place  her  case  in  the  hands  of  her 

46 


IN  ITS  RELATION  TO  SURGERY 


family  doctor.    This  would  safeguard  the  patient's  future 
welfare,  and  would  overcome  to  a  large  extent  the  grow- 
ing feeling  on  the  part  of  the  general  practitioner  that 
he  is  not  always   fairly  treated  by  the  surgeon.     Few 
surgeons  are  willing  to  turn  patients  over  to  a  physician 
immediately    after    a  serious    operation.     Complications 
are  often  so  sudden  and  dangerous,  symptoms  so  slight 
and  misleading,  diagnosis  so  difficult,  and  correct  treat- 
ment so  essential,  that  no  one  except  a  man  who  has  had 
long  and  constant  experience  in  the  management  of  this 
special   class  of  cases   is  competent  to  have  charge  of 
them.     When,  however,  the  danger  of  the  operation  is 
over,  and  the  subsequent  treatment  consists  in  regulating 
the  various  functions  of  the  body,  restoring  lost  flesh  and 
strength,   and   reestablishing  nervous   and   mental   equi- 
librium, the  family  physician  becomes  the  safer  adviser. 
With  the  rapidly  increasing  amount  of  surgery  and  the 
consequent  number  of  convalescent  patients  under  treat- 
ment, an  educational  move  ought  to  be  instituted  for  the 
study  of   the  many   peculiar   factors   involved.     Papers 
ought  to  be  written  and  discussions  ought  to  be  partici- 
pated in  by  both  surgeon  and  family  doctor,  taking  up 
the    various    details    and    discussing    them    from    their 
different  standpoints,  until  finally  there  is  evolved  a  con- 
sensus   of    opinion   with    reference    to    the   very    many 
important  points  in  the  treatment  of  these  patients.  These 
should  include  the  question  of  a  proper  dietary;  of  the 
best  method  of  regulating  the  bowels ;  of  treating  bladder 
irritation;  of  the  number  of  hours  of  sleep,  and  of  the 
necessary  periods  of  rest  during  the  day ;  of  the  amount 
of    exercise    that    is    permissible,    whether    steps    are 
injurious,  how  soon  the  sewing  machine  may  be  employed, 

47 


LATENT   AND   ACTIVE   NEURASTHENIA 

or  house  work  taken  up ;  the  question  of  driving,  riding 
horseback,  dancing,  swimming,  and  athletic  contests;  the 
sort  of  clothing  to  be  worn,  whether  corsets  are  injurious 
or  an  abdominal  binder  necessary;  the  question  of  pru- 
dence at  menstrual  periods  and  the  relief  of  pain  often 
experienced  at  that  time ;  the  treatment  of  headache,  the 
administration  of  tonics,  nervines,  and  hypnotics ;  the 
use  of  baths,  massage,  and  electricity;  the  protection  of 
wounds ;  the  employment  of  douches ;  the  use  of  tampons ; 
the  period  at  which  sexual  relations  may  be  resumed — 
these  and  a  hundred  other  questions  all  require  considera- 
tion in  order  that  they  may  be  settled. 

When  surgeons  appreciate  the  influence  of  neurasthenia 
on  the  result  of  an  operation,  and  the  influence  of  an 
operation  on  the  production  of  neurasthenia;  when  the 
family  physician  is  educated  in  the  details  of  posthospital 
treatment  and  given  legitimate  work  with  proper  com- 
pensation, then  and  not  until  then  will  there  be  harmony 
in  the  profession  and  the  greatest  good  accomplished  to 
the  greatest  number  of  patients. 


48 


Evolution  of  the  Treatment  of  Ectopic 

Pregnancy  * 

The  subject  of  ectopic  pregnancy  seems  to  have  exer- 
cised a  pecuHar  fascination  for  the  medical  mind.  Since 
its  recognition  in  the  eleventh  century  men  in  all  countries 
have  given  it  much  study. 

At  the  outset  it  is  well  to  recall  the  fact  that  rupture 
of  the  tube  usually  occurs  between  the  eighth  and  twelfth 
weeks.  If  this  danger  period  be  passed,  the  problems  of 
treatment  are  quite  distinct  from  those  in  the  early  stages. 
In  the  late  cases  nature  sometimes  attempts  a  crude 
surgery  of  her  own,  and  spontaneously  delivers  the  fetus 
by  rupture  into  the  rectum,  through  the  abdominal  wall, 
or  into  the  bladder.  As  far  back  as  the  fifteenth  century 
we  find  the  surgeons  of  that  day  operating  to  facilitate 
delivery  by  these  erratic  routes.  Primrose,  in  1594,  was 
the  first  to  undertake  section  of  the  abdomen  for  this 
purpose.  But  he,  too,  had  a  natural  suggestion  hardly 
to  be  overlooked ;  for  his  patient,  three  years  before,  had 
suffered  from  the  same  condition,  and  the  sac  had 
ruptured  through  the  abdominal  wall.  The  first  Ameri- 
can surgeon  to  perform  this  operation  was  John  Bard,  of 
New  York,  in  1759.  The  second  was  William  Baynham, 
of  Virginia,  who,  in  1791,  operated  successfully  upon 
the  wife  of  a  planter;  and  in  1799  did  another  upon  a 
negro  servant.     His  work  earned  for  him  title  to  a  high 


*  Read  in  the  Section   on   Surgery  of  the   Southern   Medical 
Association,   Lexington,   Ky.,   November,   1913. 

49 


EVOLUTION  OF  THE  TREATMENT  OF 

place  on  the  roll  of  those  country  practitioners  whose 
sturdy  self-reliance  has  so  often  done  honor,  not  only 
to  themselves,  but  to  their  profession. 

In  1842  William  Campbell,  of  Edinburgh,  published 
a  work  on  the  subject,  presenting  an  exhaustive  review 
of  the  literature  up  to  his  time.  It  did  not,  however, 
contribute  materially  to  the  evolution  of  the  treatment  in 
the  early  stages.  For  forty  years  yet  the  profession  was 
to  wander  in  a  barren  wilderness  of  half-hearted  surgical 
measures.  The  following  review  of  these  attempts  ex- 
hibits at  once  their  desperation  and  their  futility. 

1.  Destruction  of  the  Ovum  Through  the  System  of 
the  Mother. — Von  Ritgen,  in  1840,  advised  starvation 
and  purgation.  Cazeaux,  in  1861,  advocated  copious  and 
repeated  bleeding.  Keller,  in  1872,  urged  the  adminis- 
tration of  iodide  of  potash  and  mercury.  Janvrin,  in 
1874,  gave  ergotin  hypodermically.  Barnes,  in  1874,  sug- 
gested large  doses  of  strychnia,  and  later  advocated 
syphilization. 

2.  Puncture  of  Fetal  Cyst. — James  Y.  Simpson,  in 
1864,  punctured  the  fetal  cyst  through  the  vagina,  and 
evacuated  the  liquor  amnii.  The  patient  died  after  two 
days.  Hicks,  in  1865,  punctured  the  cyst  and  attempted 
to  destroy  the  fetus  by  direct  violence.  The  patient  died 
from  internal  hemorrhage  on  the  fifth  day.  Greenhalgh, 
in  1867,  punctured  the  cyst  through  the  vagina.  The 
patient  did  well  for  three  weeks,  then  had  a  chill,  abdomi- 
nal pain  and  a  bloody  vaginal  discharge.  Finally,  she 
passed  clots  and  membranes  and  recovered.  Tanner,  in 
1867,  reported  a  similar  operation.  His  patient  was 
desperately  ill  for  three  weeks,  and  then  passed  the  de- 
composing fetus  through  the  rectum.     Martin  reported 

50 


ECTOPIC  PREGNANCY 


puncturing  the  cyst  through  the  skin  of  the  abdomen. 
The  patient  died.  Thomas,  in  1875,  reported  having 
punctured  the  cyst  in  two  cases.  Both  died,  one  from 
hemorrhage  and  the  other  from  septicemia. 

3.  Removal  of  the  Embryo  by  Section  of  the  Vaginal 
Vault  ivith  the  Galvanic  Cautery. — T.  Gaillard  Thomas, 
of  New  York,  in  1875,  advocated  and  practiced  this 
method.  He  opened  the  sac,  removed  a  three-months' 
fetus,  but,  in  attempting  to  get  out  the  placenta,  had 
bleeding  and  was  forced  to  abandon  the  operation  and 
to  inject  subsulphate  of  iron  to  stop  the  hemorrhage. 
The  woman  recovered  after  a  stormy  convalescence. 

4.  Galvanism  and  Electricity. — Bachetti,  in  1857,  re- 
ported that  he  had  destroyed  a  fetus  by  inserting  needles 
into  the  cyst,  and  passing  through  them  an  electro- 
magnetic current.  Cazeaux,  in  1861,  suggested  using 
electric  shocks.  Hicks,  in  1866,  placed  one  pole  in  the 
vagina,  the  other  on  the  abdomen,  and  passed  a  galvanic 
current.  The  fetus  was  not  killed.  Barnes,  in  1874, 
used  miniature  lightning  shocks  by  means  of  a  Leyden 
jar,  one  pole  introduced  into  the  rectum  and  the  other 
into  the  vagina. 

5.  Injection  of  Narcotic  Substances  into  the  Cyst. — 
Joulin,  in  1863,  suggested  the  hypodermic  injection  into 
the  cyst,  through  the  vagina,  of  morphia  or  some  other 
narcotic  agent  to  kill  the  fetus.  Friedriech,  in  1864, 
claimed  to  have  cured  a  case  by  this  method ;  but  from 
the  history  he  gives,  it  is  doubtful  if  the  patient  really 
had  ectopic  pregnancy. 

6.  Compression  of  the  Cyst. — Malin  proposed  to  de- 
stroy the  fetus  through  severe  and  prolonged  compression 
of  the  abdomen  by  means  of  sand  bags. 

51 


EVOLUTION  OF  THE  TREATMENT  OF 

During  all  this  time  the  abdomen  was  being  opened  for 
other  purposes;  ligatures  for  the  control  of  hemorrhage 
were  in  common  use.  But  the  very  magnitude  of  the 
catastrophe  seemed  to  cause  the  profession  to  view  from 
afar  the  rational  method  of  treatment.  In  1849  Harbert 
hinted  at  the  possible  value  of  the  "Caesarean  operation." 
Again,  in  1866,  Stephen  Rogers,  of  New  York,  ventured 
to  renew  the  suggestion.  But  not  until  the  seventies  did 
opinion  begin  to  take  real  shape.  Brown  in  1870,  Routh 
in  1871,  Playfair,  Meadows  and  Darby,  of  South  Caro- 
lina, 1872,  all  wrote  advocating  what  was  then  termed 
"gastrotomy."  Spencer  Wells  and  other  leading  abdomi- 
nal surgeons  of  that  day,  however,  refused  to  carry  out 
the  suggestions;  and  Parry,  in  1876,  was  led  to  lament 
"But  no  person  has  yet  performed  gastrotomy  for  the 
relief  of  this  accident."  The  uncertainty  of  diagnosis, 
and  the  fear  of  not  being  able  to  arrest  the  hemorrhage 
after  the  abdomen  was  opened,  stayed  the  hand  of  that 
generation. 

In  1876  John  S.  Parry,  of  Philadelphia,  collected  and 
analyzed  500  cases  of  ectopic  pregnancy.  Of  these  336 
died  and  163  recovered — a  mortality  of  67.20  per  cent. 
The  recoveries  were  due,  not  to  primary  operation,  but 
to  rupture  of  the  sac  externally.  The  percentage  of  re- 
coveries (32.8  per  cent)  is  larger  than  would  be  the  case 
in  a  similar  series  today  without  operation,  because  in 
Parry's  time  many  of  the  early  fatal  cases  were  unrecog- 
nized, and  most  of  the  late  abdominal  cases  were 
recorded.  Parry  was  not  a  surgeon,  but  his  studies  led 
him  to  a  clear  conviction  of  the  treatment  to  be  followed 
in  the  early  cases,  both  before  and  after  rupture.  Being 
himself  convinced,  he  voiced  an  appeal  so  clear  and  strong 

52 


ECTOPIC  PREGNANCY 


that  the  profession,  in  the  person  of  Lawson  Tait,  was 
inspired  to  a  grapple  with  the  death-deaUng  emergency. 
But  let  Parry  speak  for  himself : 

"From  the  middle  of  the  eleventh  century,  when  Alubcasis  de- 
scribed the  first  known  case  of  extra-uterine  pregnancy,  men 
have  doubtless  watched  the  life  ebb  rapidly  from  the  pale  victim 
of  this  accident  as  the  torrent  of  blood  is  poured  into  the  ab- 
dominal cavity,  but  have  never  raised  a  hand  to  help  her.  Surely 
this  is  an  anomaly,  and  it  has  no  parallel  in  the  whole  history 
of  human  injuries.  The  fact  seems  incredible,  for  if  one  life 
is  saved  by  active  interference  it  may  be  triumphantly  pointed 
to  as  the  first  and  only  instance  of  the  kind  on  record.  In  the 
whole  domain  of  surgery — for  we  cannot  look  to  other  than 
surgical  measues  under  the  circumstances — there  is  now  left  no 
field  like  this.  In  this  accident,  if  in  any,  there  is  certain  death. 
How  often  do  we  see  persons  recover  from  injuries  which  their 
surgeons  tell  them  will  be  mortal  if  they  do  not  submit  to  a 
grave  and  terrible  operation?  .  .  .  But  in  rupture  of  'an 
extra-uterine  fetal  sac,  in  the  early  stages  of  pregnancy,  a  whole 
lifetime — a  whole  century — is  not  enough  to  enable  one  person 
to  make  two  errors  in  regard  to  the  prognosis  of  this  accident. 


"The  only  remedy  that  can  be  proposed  to  rescue  a  woman 
under  these  unfortunate  circumstances  is  gastrotomy — to  open 
the  abdomen,  tie  the  bleeding  vessel,  or  to  remove  the  sac  en- 
tire.    .     .     . 

"The  question  is  not,  Will  the  patient  die  after  the  operation? 
It  is.  Will  she  live  if  abandoned  to  nature?  This  was  answered 
in  the  sobs  and  sorrows  of  stricken  households  long  ago.     .     .     . 

"This  operation,  therefore,  appears  to  be  feasible,  at  least, 
no  one  has  demonstrated  its  impracticability,  and  in  these  days 
when  Durham  removes  the  kidney,  Pean  and  Koeberle  the  spleen 
and  Billroth  the  larynx  successfully,  this  procedure  ought  to 
be  tried." 

In  Lawson  Tait's  book  on  Diseases  of  Women  and 
Abdominal  Surgery,  published  in  1889,  we  find  recorded 

53 


EVOLUTION  OF  THE  TREATMENT  OF 

the  response  to  Parry's  appeal.  He  tells  the  story  of  a 
cai>e  to  which  he  was  called  by  a  Mr.  Hallwright,  who 
had  already  made  the  diagnosis  of  ruptured  ectopic 
gestation.     Tait  says: 

"This  gentleman  made  the  bold  suggestion  that  I  should  open 
the  abdomen  and  remove  the  ruptured  tube.  The  suggestion 
staggered  me,  and  I  am  ashamed  to  say  that  I  did  not  receive 
it  favorably.  I  saw  the  patient  again,  in  consultation  with  Mr. 
Plallwright  and  Dr.  James  Johnson,  and  again  I  declined  to 
act  upon  Mr.  Hallwright's  request,  and  a  further  hemorrhage 
killed  the  patient.  A  post-mortem  examination  revealed  the  per- 
fect accuracy  of  the   diagnosis." 

Emboldened,  or,  to  use  his  own  expression,  shamed  by 
this  incident,  on  January  17,  1883,  Tait  opened  the  ab- 
dominal cavity  for  ruptured  tubal  pregnancy.  The  first 
operation  was  unsuccessful.  He  refers  to  this  case  as 
a  bitter  disappointment,  attributing  his  failure  to  over- 
caution  and  time-consuming  work.  But,  within  the  next 
six  years,  he  had  reported  39  cases,  with  only  two  deaths. 
Truly,  through  disappointment  and  failure,  did  he  achieve 
a  triumph. 

It  is  interesting  to  note  the  different  positions  taken 
by  Parry  and  Tait  on  the  question  of  diagnosis.  Parry 
stated  as  the  greatest  impediment  to  the  adoption  of  the 
treatment  he  urged,  the  uncertainty  of  diagnosis.  Tait 
said :  'The  diagnosis  of  tubal  pregnancy  at  the  time  of 
rupture  may  be  made  with  certainty  seven  times  out  of 
eight,  and  may  be  guessed  at  in  the  eighth  instance."  He 
is  equally  postive  in  his  skepticism  of  the  diagnosis  be- 
fore rupture.  "Much  discussion,"  he  says,  "has  taken 
place  of  late  years  as  to  the  possibility  of  diagnosing  tubal 
pregnancy    before    the    period    of    rupture,    and    many 

54 


ECTOPIC  PREGNAXXY 


strangely  dogmatic  assertions  have  been  made  to  the  ef- 
fect that  such  cases  have  been  diagnosed  and  effectually 
treated.  I  am  bound  to  say  that  I  am  exceedingly  skepti- 
cal concerning  the  correctness  of  these  statements."  On 
the  other  hand,  Parry,  while  recognizing  the  difficultues, 
believed  ''that  it  may  be  discovered  at  a  much  earlier 
date  than  is  generally  supposed,"  and  that  "a  more  ex- 
tended clinical  experience  would  probably  show  that  the 
existence  of  misplaced  gestation  can  be  detected  quite  as 
easily,  if  not  more  easily,  than  normal  pregnancy  in  its 
early  stages."  This  phophecy  of  Parry's  was  not  slow 
of  fullfillment.  In  the  early  eighties  Joseph  Price,  a 
native  of  Rockingham  County,  Virginia,  and  a  pupil  of 
Tait's,  turned  his  attention  to  the  subject.  His  master- 
ful presentation  of  the  symptomatology  and  course  of  the 
disease  put  the  diagnosis  within  the  power  of  the  gener- 
al practitioner. 

With  Price  the  history  rests.  Problems  still  face  us, 
but  the  condition  was  mastered  when  Parry,  Tait  and 
Price  had  finished  their  work. 

So  much  for  the  evolution  of  the  modern  surgical 
treatment  of  ectopic  pregnancy,  because  of  its  historical 
interest.  Now  for  a  brief  discussion  of  some  of  the  still 
unsettled  questions,  because  of  their  practical  import- 
ance. 

I.  The  Question  of  Drainage. 

This  should  be  decided  by  the  special  indications  in  the 
individual  case,  but  more  often  is  governed  by  the  prac- 
tice or  prejudice  of  the  operator.  All  surgeons  drain 
some  cases,  but  some  surgeons  drain  all  cases.  The  abil- 
ity of  the  healthy  peritoneum  to  take  care  of  a  large 

55 


EVOLUTION  OF  THE  TREATMENT  OF 

quantity  of  free  blood  is  being  more  generally  recognized, 
and  injurious  irrigation  and  useless  drainage  of  the  abdo- 
minal cavity  are  now  rarely  employed.  In  a  case  of  rup- 
tured tubal  pregnancy,  unless  there  is  evidence  of  pelvic 
infection,  the  wound  may  be  safely  closed  without  drain- 
age. 

2.  The  Question  of  Saving  the  Ovary  on  the  Affected 
Side. 

This  is  not  a  question  of  principle,  but  of  practice.  We 
all  know  that  a  healthy  ovary  should  not  be  removed ;  but 
many  of  us  in  the  stress  of  critical  operations,  clamp  and 
remove  the  ovary  with  the  tube  as  the  quickest  and  easi- 
est way  of  dealing  with  the  situation.  In  many  cases  there 
will  be  no  reason  to  regret  the  method  practiced,  but  in 
other  cases  there  will  be  cause  for  regret  and  condemna- 
tion. If  disease  develops  in  the  remaining  ovary,  requir- 
ing a  second  operation  for  its  removal,  the  woman  is 
made  sterile,  suffers  from  premature  menopause,  and  fre- 
quently becomes  the  victim  of  hopeless  neurasthenia. 

3.  The  Question  of  Immediate  Operation. 

All  surgeons  agree  that  an  operation  should  be  done 
on  a  case  of  unruptured  tubal  pregnancy  as  soon  as  the 
diagnosis  is  made.  Instances  are  so  numerous  of  rup- 
ture occurring  while  the  patient  was  waiting  to  go  to  the 
hospital,  or,  while  in  the  hospital,  waiting  for  the  sur- 
geon to  come,  that  it  is  now  the  universal  practice  to  op- 
erate on  these  cases  with  the  greatest  promptness.  There 
is,  however,  a  serious  difference  of  opinion  among  the 
best  surgeons  as  to  when  to  operate  on  a  case  after  rup- 
ture occurs.    One  school  advises  an  immediate  operation 

56 


ECTOPIC  PREGNANCY 


to  arrest  the  bleeding,  claiming  that  5  per  cent  of  all  cases 
will  die  from  primary  hemorrhage,  and  if  the  patient  es- 
capes this  danger,  a  fatal  secondary  hemorrhage  may 
occur  at  any  time.  The  other  school  advises  waiting 
until  hemmorrhage  ceases,  reaction  takes  place,  and  the 
operation  can  be  done  under  more  favorable  conditions. 
They  admit  that  5  per  cent  of  the  patients  will  die,  but 
claim  that  these  cases  would  not  be  saved  unless  the  sur- 
geon was  present  at  the  time  of  the  accident  and  operated 
with  a  ''jack-knife  and  shoe  string;"  and  maintain  that  the 
greatest  good  to  the  greatest  number  is  achieved  by  wait- 
ing for  an  opportune  time  to  do  the  operation.  This  ques- 
tion has  been  so  often  fought  out  on  the  floor  of  medical 
meetings,  such  as  this,  that  most  of  my  audience  have 
formed  a  definite  opinion,  which  is  not  likely  to  be 
changed.  I  wish  to  go  on  record,  however,  as  favoring 
an  immediate  operation,  not  only  because  it  is  in  ac- 
cord with  general  surgical  principles,  but  also  because,  in 
personal  experience,  I  have  seen  the  practice  save  appar- 
ently moribund  patients. 

4.  The  Question  of  Removing  or  Ligating  the  Opposite 

Tube  to  Prevent  Repetition. 

The  frequency  with  which  a  woman,  after  being  op- 
erated on  for  pregnancy  in  one  tube  develops  the  same 
condition  later  in  the  other  tube,  makes  it  necessary  to 
consider  the  advisability  of  removing  both  tubes  at  the 
first  operation  to  avoid  a  repetition,  which  the  pathologic 
tendency  of  the  patient,  as  well  as  clinical  experience, 
makes  probable. 

The  removal  of  both  tubes  would  not  add  appreciab- 
ly to  the  danger  of  the  operation,  would  not  interfere  with 

57 


EVOLUTION  OF  THE  TREATMENT  OF 

the  function  of  menstruation,  and  would  not  increase  the 
chance  of  distressing  physical  or  nervous  sequalae.  It 
would  simply  render  the  woman  sterile.  But  is  this  de- 
sirable? To  secure  a  postive  immunity,  have  we  a  right 
to  sacrifice  a  possible  maternity  ?  This  involves  two  ques- 
tions. First,  what  proportion  of  women  operated  on  for 
tubal  pregnancy  have  a  recurrence  in  the  remaining  tube ; 
and  what  per  cent  of  women  after  such  operation  be- 
come normally  pregnant  and  give  birth  to  a  living  child? 
Second,  what  is  the  danger  of  an  operation,  and  what 
is  the  value  of  a  baby? 

The  first  question  can  easily  be  answered  by  com- 
piling statistics.  The  second  is  almost  impossible  of  so- 
lution, as  there  is  no  basis  for  comparison. 

In  191 1,  Smith,  of  Grand  Rapids,  tabulated  2,998  oper- 
ations for  tubal  pregnancy,  in  which  recurrence  followed 
in  113  cases,  or  3.8  per  cent.  He  believed  this  percentage 
was  too  low,  as  he  thought  it  was  impossible  to  follow 
up  such  cases  accurately  over  a  sufficient  period  of  time 
to  get  final  results.  His  investigation  as  to  normal  preg- 
nancy following  the  operation  was  even  unsatisfactory. 
In  thirty  of  his  own  cases,  three  had  borne  children  since 
the  operation,  one  being  pregnant  in  utero  at  the  time  of 
the  operation.  He  concluded  that  normal  pregnancy  fol- 
lowed less  frequently  than  might  be  expected. 

Essen-Moller,  of  Lund,  after  reviewing  fifty-six  cases 
of  ectopic  pregnancy  of  his  own,  and  the  reports  of 
others,  concluded  that  intra-uterine  pregnancy  may  oc- 
cur after  recovery  from  tubal  gestation  without  operation 
in  the  proportion  of  46  to  100;  and  further,  that  there 
seemed  to  be  no  difference  in  this  respect  between  the 
patients  operated  on  and  those  not  operated  on,  except 

58 


ECTOPIC  PREGNANCY 


that  drainage  after  ectopic  gestation  tends  to  make  the 
occurrence  of  intra-uterine  pregnancy  afterward  less  fre- 
quent. 

I  have  recently  reviewed  the  case  histories  of  the  last 
fifty  cases  of  tubal  pregnancy  operated  on  in  my  private 
hospital.  Six  of  these  patients  have  had  recurrence  in 
the  remaining  tube.  This  I  know,  for  I  did  the  second 
operation  myself.  There  may  be  other  cases  in  the  series 
who  went  elsewhere  for  treatment  and  who  would  add 
to  this  12  per  cent  of  repetition. 

I  have  tried  to  ascertain  how  many  of  the  patients  oper- 
ated on  for  tubal  pregnancy  subsequently  became  normal- 
ly pregnant  and  gave  birth  to  a  child.  The  result  was 
very  unsatisfactory.  One  patient  never  had  a  husband ; 
another  became  a  widow  shortly  after  leaving  the  hos- 
pital ;  some  could  not  be  located ;  others  would  not 
answer,  etc.  I  know,  certainly,  that  seven  have  borne 
one,  or  more,  children ;  and  I  believe  the  number  would 
be  doubled  if  I  could  get  the  true  figures. 

Smith,  the  author  previously  referred  to,  believes  that 
before  an  operation  for  tubal  pregnancy  the  patient 
should  have  the  situation  explained  to  her,  and  she  should 
decide  whether  or  not  the  opposite  tube  should  be  re- 
moved. But  a  woman  just  before  an  operation  for  rup- 
tured ectopic  pregnancy  is  in  no  condition  to  understand 
or  settle  a  complicated  proposition.  If  she  decides  either 
for  or  against  the  removal  of  both  tubes  she  may  regret 
the  responsibility  of  the  decision,  fearing,  on  the  one 
hand,  a  repetition  of  the  former  accident,  or  indulging 
on  the  other  in  morbid  longings  for  a  child  whose  advent 
she  has  caused  to  be  made  impossible.  The  operator 
should  settle  the  question  for  himself  without  taking  the 

59 


ECTOPIC  PREGNANCY 


woman  into  consultation,  remembering  all  the  time  that 
a  surgeon's  and  a  patient  attitude  to  an  operation  are  of- 
ten very  different,  and  that  their  estimate  of  the  desira- 
bility of  a  baby  is  often  very  far  apart. 

Personally,  I  am  opposed  to  the  removal  of  the  oppo- 
site tube,  unless  it  is  obviously  hopelessly  diseased.  If,  by 
leaving  it,  I  have  subjected  some  patients  to  a  second 
operation  that  might  have  been  avoided,  I  have  equally 
certainly  allowed  to  remain  possible  the  birth  of  some 
babies  that  otherwise  would  not  have  come  into  existence. 
As  a  surgeon  I  fear  operations  little  and  as  a  bachelor,  I 
value  babies  highly. 


60 


Cornual  Pregnancy,  With  Report  of  a 


Cas 


e 


Much  has  been  written  with  reference  to  tubal  preg- 
nancy, but  little  attention  has  as  yet  been  paid  to  cornual 
pregnancy.  A  recent  mistake  in  diagnosis  which  led  me 
to  operate  on  a  bifurcated  uterus  about  to  rupture  from 
pregnancy  in  one  of  its  horns  has  interested  me  in  the 
subject,  and  I  wish  to  report  the  case  and  briefly  discuss 
the  condition. 

Mrs.  S. ;  aged  28;  married  for  eighteen  months;  history  of 
one  miscarriage. — Patient  began  to  menstruate  at  the  usual  age 
and  her  periods  were  regular  and  natural.  Her  general  health 
was  good  and  she  had  no  reason  to  suspect  that  she  had  any 
uterine  or  other  pelvic  trouble.  In  March,  1902,  she  missed  a 
period  and  shortly  afterward  began  to  pass  blood  in  small  quan- 
tities at  frequent  intervals  from  the  vagina.  Three  months  later 
she  was  suddenly  seized  with  severe  pain  in  the  lower  right 
abdomen.  The  pain  was  characterized  as  cutting  or  tearing, 
was  attended  by  nausea  and  faintness,  and  confined  the  patient 
to  bed.  The  patient's  regular  medical  attendant  was  sent  for, 
who  stated  that  he  thought  the  trouble  was  tubal  pregnancy 
and  advised  an  operation.  Several  days  later  the  case  was 
transferred  to  me. 

I  found  the  patient  in  bed,  suffering  with  paroxysms  of  pain 
and  passing  blood  from  the  vagina.  The  abdominal  walls  were 
rigid,  but  on  making  a  bi-manual  examination  I  succeeded  in 
palpating  a  soft  but  elastic  mass  to  the  right  of  the  cervix, 
which  corresponded  exactly  in  tactile  impression  and  in  anatomi- 


*  Read  at  a  meeting  of  the  Tri-State  Medical  Association  of 
Virginia  and  the  Carolinas,  Columbia,  S.  C,  February,  1903. 

61 


CORNUAL  PREGNANCY 


cal  location  with  cases  of  unruptured  tubal  pregnancy  I  had 
previously  diagnosticated.  I  stated  that  I  agreed  with  the 
opinion  of  my  predecessor;  that  I  thought  the  case  was  un- 
doubtedly one  of  extra-uterine  gestation,  and  I  advised  im- 
mediate operative  intervention.  The  patient  was  moved  to  my 
private  sanatorium  and  as  soon  as  the  necessary  preparations 
could  be  made  the  abdomen  was  opened. 

The  uterus  I  delivered  through  the  wound  was  the  queerest 
specimen  I  ever  saw.  But  for  the  fact  that  as  a  boy  I  had  dis- 
sected many  cats  and  was  familiar  with  the  double  horned 
uterus  found  in  the  female  of  that  animal,  I  would  have  been 
at  a  loss  to  recognize  the  condition  with  which  I  had  to  deal. 

The  uterus  was  cleft  from  fundus  to  cervix;  the  two  di- 
verging sides  tapering  to,  and  terminating  in,  the  Fallopian 
tubes.  The  left  horn  was  flaccid  and  empty,  but  the  right  was 
distended  by  a  swelling  until  its  walls  were  so  thin  that  they 
were  transparent.  Evidently  the  case  was  one  of  cornual  preg- 
nancy, with  imminent  danger  of  rupture.  In  deciding  what  to 
do  I  realized  I  had  three  alternatives.  First,  I  could  return 
the  uterus,  suture  the  abdominal  wound,  and  endeavor  to  pro- 
duce an  abortion.  But  this  was  deemed  unsafe,  as  the  uterus 
might  not  have  sufficient  contractile  power  to  expel  its  con- 
tents, or  if  it  did,  would  probably  rupture  its  walls  in  the 
attempt.  Second,  I  could  incise  the  pregnant  horn,  turn  out 
the  embryo,  and  suture  the  incision  as  in  a  case  of  Caesarean 
section,  but  this  entailed  danger  of  sepsis,  and  even  if  success- 
ful would  leave  the  woman  in  a  position  to  become  pregnant 
again.  Finally,  I  could  do  a  complete  hysterectomy,  thereby 
not  only  relieving  the  present  situation,  but  also  preventing 
future  complications.  The  last  plan  was  adopted.  The  ovarian 
and  uterine  arteries  were  ligated  on  each  side,  and  the  uterus 
removed. 

The  patient  made  a  rapid  and  uneventful  recovery  and  is 
now  in  perfect  health. 

My  post-operative  study  of  available  literature  in  re- 
gard to  cornual  pregnancy  has  been  unsatisfactory.  What 
has  been  written  is  to  be  found  either  as  practical  points 

62 


WITH  REPORT  OF  A  CASE 


under  descriptions  of  uterine  malformations  or  as  inci- 
dental allusions  under  the  treatment  of  tubal  gestation. 

Cornual  pregnancy  is  not  an  extra-uterine  pregnancy, 
but  a  true  uterine  pregnancy,  which,  by  malformation  of 
the  uterus,  has  become  pedunculated  and  walled  off  from 
the  main  uterine  cavity.  The  malformation  of  the  uterus 
is  congenital  and  due  to  imperfect  fetal  development. 
The  Fallopian  tubes,  uterus,  and  vagina  are  formed  from 
two  embryonal  structures  called  the  ducts  of  Aluller. 
These  ducts  become  fused  first  at  their  lower  ends. 
Sometimes  one  duct  fails  to  develop,  so  that  the  uterus 
becomes  one  sided  or  one  horned — the  uterus  unicornis. 
Sometimes  the  ducts  may  unite  only  as  far  as  the  top  of 
the  vagina,  thus  two  distinct  uterine  bodies  resulting, 
the  double  uterus — uterus  didelphys.  Sometimes  the 
ducts  may  unite  externally  to  form  one  uterine  body, 
but  there  is  no  fusion  of  the  cavities,  which  open  sepa- 
rately, the  ttterus  bicornis  duplex. 

Sometimes  the  ducts  may  unite  to  form  a  normal  cer- 
vix, but  the  upper  part  of  the  body  of  the  uterus  is  bifur- 
cated and  the  two  sides  diverge  sharply  from  each  other, 
resulting  in  the  two  horned  uterus — the  uterus  bicornis 
unicoUis. 

Sometimes  the  ducts  may  unite  throughout,  but  exter- 
nally on  the  fundus  there  is  a  slight  depression,  demon- 
strating the  imperfection  of  development  and  giving  the 
organ  the  conventional  heart  shape — the  uterus  cordi- 
fornis. 

Finally  the  ducts  may  unite  so  that  the  uterus  presents 
externally  a  normal  appearance,  but  contains  a  septum 
which  divides  its  cavity  into  two  compartments — the 
iiterus  septus. 


CORNUAL  PREGNANCY 


The  result  of  impregnation  of  an  imperfectly  developed 
uterus  depends  on  the  degree  of  malformation,  and  the 
site  of  implantation.  Often  full  term  gestation  is  im- 
possible, no  matter  what  the  location  of  the  embryo. 
Again,  in  an  unequally  developed  uterus  pregnancy  in 
one  horn  would  probably  go  to  term,  while  in  the  other 
horn  it  would  certainly  terminate  in  abortion  or  rupture. 
Impregnation  of  the  two  horns  at  the  same  time  or  at 
different  times  is  possible,  leading  to  superfetation.  Ross, 
of  Brighton,  reports  a  case  in  which  a  patient  miscarried 
of  twins  and  three  months  later  was  delivered  of  a 
healthy,  full-term  child.  Careful  examination  showed 
the  existence  of  a  complete  double  uterus,  each  side  of 
which  had  been  impregnated.  This  woman  had  formerly 
given  birth  to  six  living  children  and  nothing  remark- 
able had  been  observed  at  any  labor. 

Symptoms  in  cornual  pregnancy  are  absent  when  the 
impregnated  horn  has  sufficient  capacity  to  accommodate 
the  growing  fetus.  Symptoms  are  present,  however, 
when  pregnancy  occurs  in  a  horn  of  the  uterus  too  rudi- 
mentary to  fulfill  the  task  imposed  upon  it.  The  symp- 
toms consist  of  intermittent  pain,  due  to  the  contraction 
of  the  muscular  coats  of  the  uterus;  bleeding  from  the 
vagina,  due  to  the  detachment  of  the  decidua  in  the 
unimpregnated  side;  and,  finally,  either  abortion  from 
discharge  of  the  contents  of  the  pregnant  horn  into  the 
uterus,  or  intra-abdominal  hemorrhage  due  to  rupture 
of   its  over-distended   walls. 

Kelly,  in  his  work  on  Operative  Gynecology,  states  that 
an  accurate  diagnosis  of  cornual  pregnancy  is  always 
difficult  to  make.  If  the  case  is  seen  after  rupture  there 
will  usually  be  no  time  to  do  more  than  determine  that 

64 


WITH  REPORT  OF  A  CASE 


there  is  intra-pelvic  hemorrhage,  due  to  an  abnormal  preg- 
nancy. If  the  case  is  seen  before  rupture  two  signs  will 
be  of  value,  the  first  that  the  developed  side  deviates  at 
an  angle  of  from  40°  to  60°  from  the  normal  position ; 
the  second,  that  the  pregnant  horn  is  found  by  rectal 
examination  to  be  connected  with  the  uterus  by  a  broad 
band  which  is  attached  at  the  lower  part  of  the  uterine 
body. 

Pregnancy  in  a  rudimentary  horn  of  the  uterus  usually 
ruptures  from  the  fourth  to  the  fifth  month,  somewhat 
later  than  is  the  case  with  tubal  pregnancy.  Authorities 
seem  to  agree  that  the  same  treatment  should  be  applied 
to  both  conditions.  If  rupture  has  occurred  the  abdomen 
should  be  opened  and  the  uterus  removed.  If  rupture 
has  not  occurred  and  pregnancy  is  still  in  the  first  six 
months  a  section  should  be  done  and  the  condition  cor- 
rected. If  the  diagnosis  is  not  made  until  after  the  sixth 
month,  then,  in  view  of  the  lessened  danger  of  rupture, 
the  operation  may  be  postponed,  provided  the  patient  can 
be  kept  under  careful  observation  until  the  child  is  viable, 
when  it  should  be  removed  by  an  abdominal  incision. 


65 


Tradition  Versus  Embryology  in 
Congenital  Malformation  * 

"And  Jacob  took  green  rods  of  poplar  and  of  almond  and  of 
plane  trees  and  peeled  them  in  part;  so  when  the  bark  was 
taken  off  in  the  parts  that  were  peeled,  there  appeared  white- 
ness; and  the  parts  that  were  whole  remained  green;  and  by 
this  means  the  color  was  divers;  and  he  put  them  in  the 
troughs,  where  the  water  was  poured  out,  that  when  the  flocks 
should  come  to  drink  they  might  have  the  rods  before  their 
eyes,  and  in  the  sight  of  them  might  conceive.  And  it  came 
to  pass  that  in  the  very  heat  of  coition,  the  sheep  beheld  the 
rods,  and  brought  forth  spotted,  and  of  divers  colors,  and 
speckled." 

Seventeen  years  ago  a  baby  with  three  legs  was  brought 
to  my  father,  Dr.  Hunter  McGuire,  for  examination  and 
advice  as  to  treatment.  The  mother  attributed  the  defor- 
mity to  a  maternal  impression.  She  stated  that  one  day 
when  she  was  about  eight  weeks  pregnant  she  heard 
strange  noises  in  her  kitchen.  None  of  the  other  mem- 
bers of  the  family  were  in  the  house  and  although  alarmed 
she  determined  to  investigate  the  cause  of  the  distur- 
bance. Going  to  the  kitchen  she  threw  open  the  door 
and  discovered  a  man  having  sexual  connection  with  her 
cook  on  the  floor.  She  seized  a  stick  and  belabored  the 
couple  until  they  fled  from  the  house. 

The  shock  of  the  incident  was  very  great  and  for 
weeks  she  was  nervous  and  hysterical.  When  awake  she 
constantly  recalled  the  sight  of  exposed  anatomy  and  at 


*  Read  at  the  meeting  of  the  Medical  Society  of  Virginia,  Nor- 
folk, Va.,   October,   1912. 

^7  .... 


TRADITION   VERSUS   EMBRYOLOGY 

night  her  dreams  were  filled  with  visions  of  moving  legs. 
She  dreaded  the  effect  on  her  unborn  child  and  her  fears 
seemed  realized  in  the  deformity  already  mentioned. 

On  examination  the  baby  was  found  to  be  healthy  and 
well  developed.  He  had  three  legs  of  equal  size  and 
length.  The  extra  limb  was  attached  to  the  pubis  above 
the  penis.  Except  for  a  double  foot  it  was  symmetrical 
with  the  other  legs.  When  the  child  lay  on  his  back  he 
kicked  vigorously  with  all  three  legs  and  sucked  the  toes 
of  each  with  perfect  impartiality. 

The  case  was  exhibited  at  the  clinic  of  the  University 
College  of  Medicine  and  at  the  time  attracted  much  at- 
tention. My  father  advised  the  woman  to  take  the  boy 
home  and  return  when  he  was  two  or  three  years  old 
to  have  the  superfluous  leg  amputated. 

Nothing  further  was  heard  of  the  case  until  last  June 
when  the  patient  walked  into  my  office.  He  was  a  stal- 
wart youth,  evidently  accustomed  to  outdoor  work,  and 
weighed  about  one  hundred  and  fifty  pounds.  His  gener- 
al health  was  excellent  but  the  extra  leg,  he  said  was  a 
nuisance  and  he  wanted  to  get  rid  of  it. 

On  stripping  the  boy  I  found  he  carried  the  third  leg 
extended  on  his  abdomen  and  chest,  the  limb  being  kept 
in  place  by  means  of  a  strap  which  encircled  the  body. 
Owing  to  long  disuse  the  leg  was  much  emaciated  but  its 
length  was  approximately  that  of  the  other  limbs.  The 
leg  was  attached  to  the  patient's  body  by  three  bony 
processes,  a  median  and  two  lateral.  They  sprang  from 
the  anterior  surface  of  the  pubic  bones  and  united  in  a 
knob  that  formed  the  acetabular  cavity. 

The  head  of  the  femur  was  perfectly  formed.  The 
knee-joint  was  normal  except  that  it  had  no  patella.   The 

68 


Fig.  1— Photograph  of  Patient. 


IN  CONGENITAL  MALFORMATION 

foot  was  deformed  and  had  nine  toes.  The  accompany- 
ing photograph  and  X-ray  pictures  give  a  better  idea  of 
the  patient's  condition  than  any  verbal  description. 

I  operated  on  the  boy  at  St.  Luke's  Hospital  on  June 
i8,  1912,  incising  the  soft  structures  and  cutting  the  bony 
attachments  to  the  pelvis  with  a  chisel  and  mallet.  The 
patient  made  a  rapid  and  uninterrupted  recovery  and  a 
recent  letter  states  that  he  is  now  well  and  doing  manual 
work  on  the  farm. 

The  case  is  reported  partly  because  it  is  unusual  and 
interesting,  but  chiefly  because  it  again  raises  the  much 
discussed  question  of  the  influence  of  maternal  impres- 
sions on  fetal  development. 

Belief  in  the  efficacy  of  some  profound  impression  upon 
the  mother  to  produce  upon  the  body  of  her  unborn  child 
a  direct  and  definite  effect  coinciding  more  or  less  accur- 
ately with  the  object  causing  the  impression,  began  ap- 
parently with  the  dawn  of  history  and  in  certain  quarters 
exists  today  with  scarcely  less  prestige  than  it  did  a  thous- 
and years  ago. 

The  biblical  incident  recording  the  success  of  Jacob's 
stratagem  with  the  peeled  rods  reads  no  more  strangely 
than  the  gravely  recited  case  of  a  great  present-day 
authority  whose  pregnant  patient,  after  being  seized  by 
an  ear  and  dragged  about  the  room  by  her  drunken 
spouse,  gave  birth  to  a  child  having  a  triangular  piece 
lacking  from  the  corresponding  lobe  of  the  ear. 

In  the  realm  of  fiction  and  philosophy  we  find  Dickens, 
Goethe,  Scott  and  others  of  equal  note  apparently  firm' 
adherents  of  the  impressionistic  idea,  and  the  great  mass 
of  medical  testimony  of  their  day  decidely  of  their  point 
of  view.    Even  at  the  present  time  we  find  cases  of  sup- 

69 


TRADITION   VERSUS   EMBRYOLOGY 

posed  maternal  impression  reported  so  frequently  in  our 
scientific  journals  that  one  questions  why  there  is  either 
not  a  world  full  of  monsters  or  else  a  race  of  rare  and 
radiant  beings  moulded  at  will  by  professional  guardians 
of  impressionable  mothers.  Associated  with  the  belief 
in  maternal  impression  is  a  cloud  of  superstition  with 
reference  to  the  nature  and  the  cause  of  monstrosities. 
The  purposes  of  this  paper  do  not  permit  even  mention 
of  the  various  fanciful  theories  which  attributed  the  ori- 
gin of  terata  to  the  sport  of  the  gods,  to  the  anger  of 
offended  Deity,  to  cohabitation  with  Satan,  to  a  malign 
stellar  assemblage,  or  to  one  or  another  of  a  hundred 
more  causes. 

With  the  discovery  of  the  ovum  and  the  advent  of 
modern  embryological  research,  the  theory  of  maternal 
impression  suffered  some  decline,  but  the  stubborn  re- 
currence of  fresh  ''proofs"  has  invariably  fanned  the 
flame  whenever  it  seemed  in  serious  danger  of  flickering 
out.  As  we  have  said  these  proofs  are  still  accumulating 
and  the  result,  in  our  own  day,  is  that  while  the  theory 
has  lost  many  adherents,  particularly  in  the  professional 
ranks,  it  is  still  firmly  rooted  in  the  minds  of  the  laity, 
and  indeed  yet  claims  the  serious  attentions,  if  not  the 
actual  outright  belief  of  many  trained  medical  men.  An 
examination  of  numerous  obstetric  texts  of  recent  years 
reveals  a  degree  of  credulity  astounding  to  the  modern 
scientific  enquirer.  So  considerable  an  authority  as  Hirst 
states  in  his  fifth  edition  that  there  are  "well  authenti- 
cated cases  of  congenial  defects  or  peculiarities  which 
bear  too  startling  a  resemblance  to  the  cause  of  the  im- 
pression upon  the  mother  during  pregnancy  to  be  dis- 
missed as  mere  coincidence."     Many  more  names  might 

70 


Fig.  2— X-Ray  of  Knee  Joint. 


IN  CONGENITAL  MALFORMATION 

be  added  to  the  list  and  from  the  rank  and  file  of  the 
profession  might  easily  be  collected  a  legion  of  those  who 
have  observed  in  private  practice  enough  to  win  them  to 
the  ancient  superstition. 

These  men  are  as  earnest  and  as  thoughtful  as  we  and 
it  is  by  no  means  the  effort  of  this  paper  to  cast  ridicule 
upon  those  who  honestly  hold  to  convictions  opposed  to 
our  own ;  at  the  same  time  the  subject  is  of  such  practical 
importance  that  if  we  can  show  the  impressionists  the 
error  of  their  way  we  shall  have  served  many  anxious 
mothers  well  and  gained  a  step  amply  repaying  the  loss 
of  a  few  broken  idols.  The  pregnant  woman  already  has 
to  endure  enough  without  being  constantly  harried  with 
the  dread  that  some  temperamental  excess  will  stamp  her 
child  for  life  or  some  accident  will  cause  her  to  bring  into 
the  world  a  monster  upon  which  man  will  hate  to  gaze. 

Would  it  not  be  a  boon  to  the  expectant  mother  to  have 
it  authoritatively  stated  that  she  can  now  dismiss  at  least 
this  one  danger  of  her  pregnancy  ?  Is  it  not  time  for  us 
to  realize  that  we  are  sheltering  a  superstition  and  en- 
couraging unnecessary  fears,  instead  of  relieving  the  men- 
tal stress  of  a  class  of  patients  often  painfully  in  need  of 
a  comforting  word  ? 

At  the  outset  it  is  well  enough  to  admit  that  as  yet  the 
embryological  evidence  advanced  in  contradiction  of  the 
impressionistic  idea  is  neither  clear  nor  definite,  though 
it  is  of  sufficient  weight  to  warrant  the  belief  that  we  are 
actually  approaching  an  understanding  of  some  hitherto 
baffling  problems  involving  not  alone  this  idea  but  the 
whole  vexed  question  of  heredity  itself.  At  the  same 
time  it  cannot  be  denied  that  when  the  negative  results 
of  maternal  impressions  are  ignored,  as  is  persistently 

71 


TRADITION   VERSUS   EMBRYOLOGY 

done,  and  the  long  list  of  cited  cases  are  considered  on 
their  face  without  regard  to  whether  or  not  they  clash 
with  scientific  probability  as  justified  by  modern  research, 
the  argument  might  well  be  convincing  to  the  laity,  and 
even  to  the  members  of  the  profession  who  by  habit  or 
inclination  have  come  to  value  their  eyes  and  ears  more 
than  their  microscopes. 

A  careful  study  of  the  cases  reported  in  the  past  and 
a  close  scrutiny  of  the  instances  likely  to  arise  in  the 
future  will  show  that  in  the  vast  majority  the  impression 
which  was  supposed  to  have  left  its  mark  upon  the  fetus 
occurred  long  after  the  development  of  the  affected  part. 
Embryologists  have  proved  rather  conclusively  that  the 
matrix  of  the  new  being  is  laid  down  during  the  first  five 
weeks  of  intrauterine  life  and  that  thereafter  the  process 
is  concerned  no  longer  with  the  production  of  new  parts 
but  chiefly  with  the  mere  growth  of  those  already  formed. 
In  other  words  organogenesis  takes  place  before  the 
mother  even  knows  she  is  pregnant  and  impressions  oc- 
curring thereafter  can  no  longer  affect  the  type,  certainly 
so  far  as  multiplicities  are  concerned. 

When  due  consideration  is  given  to  the  negative  evi- 
dence against  the  theory,  the  cases  cited  in  its  support 
seem  pitifully  few  and  inadequate.  Indeed  we  have  right 
here  what,  to  most  of  us  is  sufficient  to  dispose  of  the 
assumption,  for  to  view  on  the  one  side  the  vast  num- 
ber of  unimpressed  and  on  the  other  the  isolated  few 
who  bear  the  stamp  gives  us  ample  warrant  for  the 
conclusion  that  the  few  are  the  result  of  chance  and  not 
of  rule.  There  is  in  all  the  realms  of  science  no  natural 
process  that  deals  only  in  exceptions,  and  when  we  meet 
such  a  situation  we  can  safely  question  and  refuse  to  ac- 

72 


Fig.  3-X-Ray  of  Foot. 


IN  CONGENITAL  MALFORMATION 

cept.  Were  the  impressionistic  theory  true,  as  many  be- 
lieve, then  would  we  be  wondering  and  worrying,  not 
over  those  afflicted  as  we  do  now,  but  over  the  good  for- 
tune of  those  who  escaped. 

But  though  we  accept  the  evidence  of  the  many  we 
must  somehow  account  for  the  few  and  therefore  what  is 
the  "chance"  to  which  we  have  attributed  their  existence? 
The  appeal  to  "coincidence"  often  cloaks  mere  ignorance, 
but  we  employ  the  word  here  deliberately  and  with  full 
regard  for  the  improper  uses  to  which  it  has  so  frequently 
been  put.  With  the  existence  on  the  one  hand  of  a  series 
of  possible  irregular  forms  of  development  and  on  the 
other  a  series  of  possible  impressions  upon  the  pregnant 
woman,  does  it  seem  strange  that  occasionally  the  two 
series  should  coincide. 

There  are  many  deep-rooted  superstitions  founded 
upon  just  this  coincidence.  No  argument  however  pro- 
found can  convince  the  old  woman  whose  "man"  gave  up 
the  ghost  soon  after  a  sparrow  perched  upon  the  window 
ledge  and  pecked  at  the  pane.  '7  seen  it"  is  her  sole, 
withering  and  all-satisfying  answer,  and  it  must  be  admit- 
ted that  to  those  who  judge  all  things  by  the  evidence  of 
their  own  eyes  and  ears  the  appeal  is  a  powerful  one. 
And  yet  with  window-pecking  sparrows  surrounding  us 
and  death  ever  lurking  near,  it  appears  not  unreasonable 
to  believe  that  once  in  a  while  the  visitation  of  the  Grim 
Reaper  and  the  curiosity  of  the  sparrow  should  coincide. 

Before  passing  from  this  point  it  may  be  remarked 
also  that  the  pregnant  state  is  peculiarly  adapted  to  unin- 
tentional self-deception  and  that  many  of  the  cited  cases 
cannot  even  claim  the  dignity  of  coincidence  being  merely 
ex  post  facto  explanations  suggested  by  the  deformity. 

73 


TRADITION  VERSUS   EMBRYOLOGY 

In  other  words,  we  can  find  that  the  deformity  produces 
the  impression  in  many  instances  instead  of  the  impres- 
sion producing  the  deformity.  When  a  woman  discovers 
in  her  child  some  pecuHar  mark  it  is  easy  enough  to 
search  through  nine  months  of  incidents,  impressions, 
dreams,  emotions,  fears  and  what  not  and  find  something 
remotely  resembling  it. 

The  discovery  of  the  reduction  and  division  of  the 
chromosomes  and  the  realization  of  its  immense  import- 
ance as  the  basis  for  a  satisfactory  theory  of  heredity 
marked  an  important  advance  and  as  Piersol  says  "has 
given  to  our  knowledge  of  fertilization  an  almost  mathe- 
matical precision  and  supplied  an  accurate  morphological 
basis  for  our  understanding  of  heredity."  We  seem  here 
on  the  very  threshold  of  that  long-sought  scientific  knowl- 
edge of  the  laws  governing  the  transmission  of  peculiari- 
ties from  generation  to  generation. 

As  for  the  aberrant  types  and  the  variations  which  are 
not  transmitted  from  generation  to  generation  but  are  pe- 
culiar to  the  individual  in  question,  in  other  words,  those 
often  claimed  to  have  been  ''impressed"  upon  the  fetus 
through  the  mind  of  the  mother,  the  biologist  also  has  his 
authoritative  word. 

It  has  already  been  noted  that  the  details  of  the  orga- 
nism are  determined  in  miniature  in  the  early  weeks  be- 
fore the  woman  even  realizes  she  is  pregnant.  It  should 
also  be  stated  that  during  this  early  period  before  the 
placenta  has  developed,  there  is  no  organic  connection  be- 
tween the  segmenting  ovum  and  the  parent.  Except  that 
the  one  rests  within  the  other,  the  two  in  the  human  be- 
ing during  this  early  period  are  as  distinct  as  the  chicken 
egg  from  the  hatching  hen.    This  being  true,  it  is  difficult 

74 


IN  CONGENITAL  ]\IALFORMATION 

to  see  how  impressions  could  pass  between  the  two.  Later 
on,  after  the  placental  circulation  has  developed  and 
the  child  begins  to  thrive  upon  the  mother,  there  is  indeed 
a  definite  connection,  but  now  the  embryonal  or  develop- 
mental stage  has  been  passed  and  the  stage  of  new  growth 
begun.  Hence,  even  were  the  organic  connection  com- 
plete, impressions  could  no  longer  affect  the  fetus  in  the 
sense  of  producing  multiplicities  or  duplicities,  though 
they  might  place  their  stamp  upon  organs  or  parts  al- 
ready formed.  But  the  organic  connection  is  by  no 
means  complete.  There  is  absolutely  no  link  between  the 
nervous  system  of  the  mother  and  that  of  her  offspring, 
and  since  the  impressionist  evidently  assumes  that  the  ex- 
ternal cause  operates  through  the  mind  of  the  parent,  we 
are  at  a  loss  to  see  how  it  bridges  this  gap.  While  the 
mother  bears  her  child  she  merely  supplies  it  with  the 
food  necessary  for  its  growth.  There  is  even  no  admix- 
ture of  blood,  the  transmission  being  affected  by  osmosis 
through  a  definite  membrane  which  may  be  demonstrated 
with  the  microscope.  If  the  hen  could  speak  we  would 
probably  learn  vastly  more  of  the  impressionists'  side  of 
the  case,  since  monstrosities  are  much  more  common  in 
birds  than  in  mammals,  and  the  process  must  be  much 
more  complex,  the  &gg  lying  entirely  outside  the  body  and 
the  "impression"  having,  therefore,  to  travel  a  long  dis- 
tance through  feathers,  space  and  shell.  Similarly  the 
incubator,  were  it  not  dumb,  might  throw  much  light  on 
the  problem  and  entertain  us  with  an  account  of  the  im- 
pressions which  it  transmitted  to  the  artificially  hatched 
chickens  in  which  strange  deformities  are  so  often  found. 
And  now  what  can  we*  say  of  the  real  cause  of  these 
anomalies?     "They  are  the  result,"  says  Ballantyne,  "of 

75 


TRADITION  VERSUS   EMBRYOLOGY 

disorderly  embryology,  or  disturbed  ontogenesis  and  or- 
ganogenesis ;  many  of  them  are  arrested  developments  and 
represent  the  stage  which  ought  to  have  been  temporary 
in  ontogenesis,  but  which  have  remained  stationary  while 
other  and  neighboring  parts  were  pursuing  the  path  of 
normal  development."  The  marvellous  combinations  and 
recombinations  by  which  the  three  primary  blastodermic 
layers  are  woven  into  the  human  texture  certainty  offer 
enough  field  for  an  occasional  incongruous  thread,  par- 
ticularly when  it  is  remembered  that  the  loss  of  a  few 
cells  in  the  embryonic  period  may  mean  the  absence  of 
the  entire  organ  into  which  they  would  subsequently  have 
developed.  Hence  it  needs  no  cataclysm  to  produce  ''dis- 
orderly embryology"  and  the  influence  of  several  definite 
factors  has  been  more  or  less  definitely  proven.  The 
germ  plasm  itself  may  be  defective.  Intrauterine  pres- 
sure, and  even  external  traumatism,  may  so  disturb  the 
fetus  as  to  affect  its  development.  Malposition  of  the 
fetus  in  utero,  abnormal  diminution  of  the  amniotic  space 
and  adhesion  of  the  membrane  to  the  fetal  parts  may  all 
profoundly  affect  development,  as  has  been  proven  by 
numerous  authenticated  cases. 

Finally,  the  state  of  the  fetus  may  be  seriously  affected 
by  the  general  condition  of  the  parent.  It  is  conceivable 
that  a  profound  shock  might  so  severely  affect  the  health 
of  the  mother  as  to  impair  the  decidual  circulation  and 
thus  harm  the  child  by  an  insufficient  supply  of  food- 
laden  blood.  The  disturbance  may  be  so  severe  as 
to  produce  outright  abortion  or  it  may  be  less  severe  and 
merely  cause  defective  growth.  But  this  is  a  very  dif- 
ferent thing  from  shocking  into  existence  a  new  leg  or  a 

76 


IN  CONGENITAL  MALFORMATION 

frog-like  head  when  both  leg  and  head  have  already  been 
normally  and  perfectly  developed. 

With  reference  to  the  case  cited  at  the  beginning  we, 
therefore,  attach  no  significance  to  the  mother's  explana- 
tion, preferring  to  believe  that  it  is  but  another  instance 
of  ^'disorderly  embryology"  in  the  production  of  which 
external  impressions  had  no  part. 


17 


Treatment  of   Diffuse  Suppurative 
Peritonitis  ^ 

In  studying  the  subject  of  suppurative  peritonitis  it 
soon  becomes  apparent  that  the  differences  in  the  views 
of  various  authors  with  reference  to  certain  types  of  the 
disease  are  due  to  a  faihu'e  to  adopt  the  same  classifi- 
cation, and  to  a  lack  of  a  clear  conception  of  what  is 
meant  by  the  terms  employed.  We  read  of  septic  peri- 
tonitis, local  suppurative  peritonitis,  general  suppura- 
tive peritonitis  and  diffuse  suppurative  peritonitis. 

The  term  septic  peritonitis  should  be  employed  to  des- 
ignate those  cases  in  which  the  pyogenic  infection  is  so 
acute  and  virulent  that  the  patient  dies  before  sufficient 
time  has  elapsed  for  pus  to  form. 

The  term  local  suppurative  peritonitis  should  be  em- 
ployed to  indicate  those  cases  in  which,  owing  to  the 
character  of  the  infection,  pus  develops  slowly  and  na- 
ture has  time  to  form  adhesions  which  confine  the  pus 
to  a  limited  portion  of  the  peritoneal  cavity. 

The  term  diffuse  suppurative  peritonitis  should  be  re- 
served to  designate  the  conditions  in  which  the  infection 
is  less  virulent  than  in  septic  peritonitis,  but  more  acute 
than  in  local  suppurative  peritonitis;  where  there  is  time 
for  pus  to  form,  but  not  time  for  nature  to  wall  it  in  by 
adhesions,  and,  as  a  consequence,  pus  is  free  in  the  peri- 
toneal cavity. 


*  Read  at  meeting  of  the  Southern  Surgical  and  Gynecological 
Association,  New  Orleans,  December,   1907. 

79 


TREATMENT  OF 


The  term  general  suppurative  peritonitis  should  be 
discarded.  It  was  originally  used  in  contradistinction  to 
local  suppurative  peritonitis,  and  while  its  meaning  should 
be  apparent  it  has  been  misconstrued,  thus  giving  cause 
for  much  discussion.  The  term  was  never  intended  to 
mean  that  the  whole  peritoneal  surface  was  involved. 
The  word  "general"  was  used  to  indicate  that  the  pus 
was  free,  in  contrast  with  the  word  ''local,"  where  it  was 
confined.  To  avoid  recurrence  of  unprofitable  argument 
and  the  statement  by  some  that  no  patient  with  general 
suppurative  peritonitis  ever  recovered,  and  the  reply  by 
others  that,  as  the  term  was  employed,  no  patient  ever 
lived  long  enough  to  develop  it,  it  is  to  be  hoped  that  the 
title,  general  suppurative  peritonitis,  will  be  dropped  from 
surgical  nomenclature,  and  diffuse  suppurative  peritonitis 
substituted  for  it. 

The  confusion  alluded  to  in  the  classification  of  peri- 
tonitis is  responsible  for  the  condition  which  existed  ten 
years  ago,  when  Abbe,  McBurney,  Finney  and  others 
were  reporting  numerous  successful  operations  for  gen- 
eral suppurative  peritonitis,  while  at  the  same  time,  Senn 
declared  that  he  had  opened,  drained  and  washed  out  the 
general  peritoneal  cavity  in  many  cases  of  septic  peri- 
tonitis without  a  single  successful  result;  Weir  that  he 
had  never  been  able  to  save  a  patient  with  general  sup- 
purative peritonitis,  and  had  never  seen  one  saved ;  and 
Granvin  that,  until  recently,  he  had  expected  death  after 
general  purulent  peritonitis  and  was  not  at  all  ashamed 
of  his  mortality  rate  of  lOO  per  cent.  At  this  period, 
and  for  some  years  afterward,  the  accepted  mode  of 
treatment  was  incision  and  removal  of  the  focus  of  in- 

80 


Fig.  4 — Bed  Elevators 


DIFFUSE  SUPPURATIVE  PERITONITIS 

f  ection :  evisceration,  irrigation  and  sponging ;  counter 
incisions  through  the  loins  and  the  insertion  of  multiple 
drains.  The  result  was  a  mortality  of  about  80  per  cent. 
The  present  generally  accepted  method  of  treatment 
was  not  adopted  empirically,  but  was  the  result  of  de- 
ductions from  scientific  observations.  Its  essential  fea- 
tures consist  of  Fowler's  position  and  Murphy's  procto- 
clysis :  hence,  it  may  properly  be  called  the  Fowler-Mur- 
phy treatment.  In  justice  to  others,  however,  the  fol- 
lowing history  of  the  evolution  of  the  method  is  given : 

Muscatello  demonstrated  that  the  peritoneum  of  the 
upper  abdomen,  or  diaphragmatic  region,  possesses  much 
greater  and  more  rapid  absorptive  power  than  the  peri- 
toneum of  the  lower  abdomen  or  pelvic  region.  Clark 
saw  the  possibilities  of  postural  drainage  and  advised  ele- 
vating the  foot  of  the  patient's  bed,  thus  throwing  fluid, 
by  gravity,  to  the  surface  which  would  most  rapidly  ab- 
sorb it.  Fowler  said  that  the  principle  of  postural  drain- 
age was  correct,  but  its  application  was  wrong;  that  the 
fluid  should  not  be  drained  into  the  patient,  but  out  of 
him.  Fie  advised  elevating  the  head  of  the  bed  to  allow 
the  fluid  to  gravitate  from  the  diaphragm  where  it  would 
be  absorbed,  to  the  pelvis  where  it  would  be  collected 
until  removed  by  a  drain.  Bond  demonstrated  that  par- 
ticles of  indigo-carmine  placed  inside  the  anus  would  be 
carried  upward  by  what  he  termed  "reverse  mucous  cur- 
rents." Cannon  showed  that  except  during  defecation 
antiperistalsis  is  the  normal  movement  in  the  large  intes- 
tine, and  that,  owing  to  this  fact,  liquid  feces  are  carried 
back  into  the  cecum,  where  the  watery  element  is  ab- 
sorbed. 

81 


TREATMENT  OF 


Murphy  suggested  utilizing  the  foregoing  observation 
in  the  treatment  of  suppurative  peritonitis,  by  injecting 
saHne  solution  slowly  into  the  rectum,  depending  on  re- 
verse peristalsis  to  carry  it  to  the  cecum  where  it  would 
be  absorbed.  He  reasoned  that,  owing  to  the  patient  be- 
ing unable  to  take  as  much  water  as  was  being  elimi- 
nated, he  became  dehydrated  and  the  empty  vessels  of 
the  peritoneum  rapidly  absorbed  any  fluid  the  cavity 
contained.  If,  by  introducing  a  large  quantity  of  fluid 
into  the  circulation,  the  vessels  could  be  overfilled,  then 
the  peritoneum  would  be  changed  from  an  absorbing  sur- 
face to  a  secreting  surface,  and  in  place  of  toxic  fluids 
going  into  the  circulation,  there  would  be  a  flow  of  cleans- 
ing serum  into  the  peritoneal  cavity. 

The  practical  steps  of  the  Fowler-Murphy  method  are 
as  follows :  Open  the  abdomen  over  the  seat  of  the  pri- 
mary focus  of  infection  and  correct  the  trouble,  whatever 
it  may  be,  so  as  to  prevent  the  admission  of  further  poi- 
son. Make  a  second  short  incision  immediately  above 
the  pubes,  and  insert  a  large  rubber  drain  to  the  bottom 
of  the  pelvis.  The  work  should  be  rapid,  with  as  little 
manipulation  of  the  viscera  as  possible,  and  no  effort 
should  be  made  to  remove  the  pus  by  sponging  or  irriga- 
tion. Place  the  patient  in  bed  in  an  exaggerated  Fow- 
ler's position.  Give  saline  solution  by  continuous  low- 
pressure  rectal  instillation ;  administer  morphine,  in  small 
doses,  for  pain  and  spartein,  in  large  doses,  as  a  general 
stimulant  and  prophylactic  against  suppression  of  urine. 
Purgatives  should  not  be  employed,  but  bowel  action  se- 
cured by  the  cautious  use  of  enemata.  If  there  is  much 
nausea  or  vomiting  the  stomach  should  be  thoroughly  irri- 

82 


Fig.  5— Bed  Seat 


DIFFUSE  SUPPURATIVE  PERITONITIS 


gated,  and  no  food  should  be  given  until  the  patient  can 
retain  and  assimilate  it. 

By  the  adoption  of  the  method  outlined  I  have  seen 
a  great  change  in  my  mortaHty.  A  recent  analysis  of 
the  last  500  cases  of  appendicitis  operated  on  in  my  pri- 
vate hospital  gives  a  record  of  twenty-four  patients  with 
diffuse  suppurative  peritonitis.  The  first  six  were 
treated  by  the  old  method  of  irrigation  and  multiple 
drainage,  with  five  deaths.  The  last  eighteen  were  treated 
by  the  Fowler-Murphy  method,  with  but  one  death. 

Coffey  has  demonstrated  that  there  are  three  cavities 
or  basins  of  the  peritoneum  to  be  drained — the  right  and 
left  flank,  separated  from  each  other  by  the  spinal 
column  and  the  pelvis,  separated  from  the  flanks  by  the 
psoas  muscle.  When  the  body  is  horizontal  each  flank 
holds  more  fluid,  and  is  deeper  than  the  pelvis.  The 
bottom  of  the  flank  cavity  is  four  inches  below  the  top 
of  the  divide  made  by  the  psoas  muscle.  Hence,  theoret- 
ically, a  patient's  body  must  be  elevated  to  an  angle  of 
50  degrees  to  permit  gravity  drainage  of  the  flanks.  I 
have  found  great  difliculty  in  maintaining  a  patient  in 
this  position,  and  recently,  in  visiting  various  hospitals, 
I  have  always  inquired  what  method  or  apparatus  was 
employed  in  managing  such  cases. 

I  have  found  two  principles  in  practice,  angulation  of 
the  patient  and  angulation  of  the  bed.  The  first  is  ef- 
fected by  keeping  the  bed  horizontal  and  elevating  the 
patient's  body  by  means  of  a  shoulder  rest;  the  second, 
by  elevating  the  head  of  the  bed  and  allowing  the  patient 
to  lie  flat  on  the  inclined  mattress.  As  one  method  must 
be  superior  to  the  other,  I  have  given  their  relative  merits 

83 


TREATMENT  OF 


considerable  thought.  The  advantage  claimed  for  the 
"semi-sitting  position"  over  "bed-elevation"  is  that  it  gives 
better  drainage.  This  I  do  not  beheve  is  true,  because,  as 
I  will  try  to  show,  it  is  impossible  to  maintain  a  patient 
in  the  proper  position  on  a  shoulder  rest,  while  it  is  an 
easy  matter  to  prevent  his  slipping  on  an  inclined  mat- 
tress, no  matter  what  the  elevation. 

The  disadvantages  of  the  semi-sitting  position  are: 
(i)  It  makes  it  difficult  for  the  nurse  to  place  the  bed- 
pan properly;  (2)  it  is  unnatural  and  subjects  the  patient 
to  mental  and  muscular  tension;  (3)  he  will  slip  down 
when  relaxed  by  weakness  or  sleep,  so  that  his  body  will 
bend  at  the  costal  arch  and  his  abdomen  will  be  on  a 
plane  parallel  with  the  surface  of  the  bed.  To  prevent 
the  tendency  to  assume  this  false  position,  some  sur- 
geons use  auxiliary  straps  attached  to  the  shoulder  rest; 
some  a  double  inclined  plane  to  support  the  legs ;  and 
others  go  so  far  as  to  elevate  the  foot  of  the  bed.  None 
of  these  methods,  however,  satisfactorily  corrects  the 
trouble. 

The  advantages  of  elevating  the  head  of  the  bed  are: 
( I )  The  mattress  may  be  put  at  any  angle ;  (2)  the  patient 
lies  on  a  flat  surface,  often  unconscious  of  his  position; 
and  (3)  he  is  completely  relaxed  and  easily  nursed.  The 
difficulty  experienced  in  managing  this  position  has  been 
to  get  a  simple  device  for  raising  or  lowering  the  head  of 
the  bed,  and  to  devise  a  means  to  prevent  the  patient  from 
sliding  down  the  incline.  Blocks,  boxes  and  tables  have 
been  used  for  the  first,  and  pillows,  hammocks  and  swings 
placed  beneath  the  buttocks  and  attached  to  the  head  of 
the  bed,  for  the  second. 

84 


Fig.  6    Bed  in  Moderate  Elevation 


DIFFUSE  SUPPURATIVE  PERITONITIS 

I  herewith  present  a  model  and  photographs  of  a  sim- 
ple and  cheap  apparatus  which  I  have  employed  for  more 
than  a  year  to  accomplish  both  of  the  desired  ends.  The 
bed  elevator  (Fig.  i)  consists  of  a  wooden  base  and  up- 
right piece.  There  are  a  number  of  notches  on  the  side 
of  the  upright,  into  which  fits  an  iron  link  which  supports 
a  block  to  receive  the  leg  of  the  bed.  The  link  when 
horizontal,  slips  up  or  down,  but  when  oblique  fits  into 
a  notch,  just  as  does  the  lock  of  an  ordinary  needleholder. 

The  bed  seat  (Fig.  2)  consists  of  a  board  which  either 
bare  or  padded  with  a  pillow,  makes  a  shelf  on  which 
the  patient  sits.  A  wooden  shaft  projects  downward  and 
passes  through  a  second  board  which  rests  against  the 
foot-piece  of  the  bed  (Fig.  3).  In  the  shaft  are  a  num- 
ber of  holes,  and  a  peg  placed  in  one  of  them  will  pre- 
vent the  shaft  from  passing  through  the  bottom  board, 
and  thus  transfer  the  weight  of  the  patient  to  the  foot 
of  the  bed. 

The  advantages  of  the  bed  seat  over  a  hammock  or 
swing  are  its  rigidity  and  consequent  sense  of  security 
given  the  patient ;  the  ease  with  which  it  can  be  removed 
and  replaced  by  the  nurse  when  it  is  found  necessary  to 
do  so ;  and  also  the  fact  that  there  are  no  straps  or  ropes 
on  either  side  of  the  patient's  head  or  body  to  embarrass 
the  nurse  or  alarm  the  relatives.  Both  of  the  devices 
described  can  be  made  by  any  carpenter  at  the  cost  of 
a  few  dollars,  and  will  securely  maintain  the  patient  at 
any  angle  for  any  time  without  discomfort. 


85 


The  Surgical  Treatment  of  Dyspepsia* 

A  generation  ago  nearly  all  of  our  knowledge  with 
reference  to  diseased  conditions  was  derived  from  post- 
mortem examinations  made  by  pathologists.  Today  much 
of  our  information  is  derived  from  ante-mortem  examin- 
ations made  by  surgeons.  Observations  taken  during  the 
early  stages  of  disease  before  the  initial  lesions  are  ob- 
scured by  secondary  complications  and  terminal  infections 
have  changed  many  of  the  theories  formerly  held  by  the 
profession,  and  in  no  instance  has  this  been  more  radical 
than  with  reference  to  the  so-called  ''dyspepsia." 

It  was  formerly  taught  that  indigestion  was  purely  a 
functional  disturbance  of  the  stomach  to  be  treated  by 
hygienic,  dietetic  and  medicinal  measures ;  it  is  now  ac- 
cepted that  indigestion  when  chronic  or  recurrent  is  al- 
most invariably  caused  by  organic  changes  in  the  stomach, 
duodenum,  gall-bladder  or  appendix,  and  that  relief  from 
symptoms  can  only  be  permanently  secured  by  surgical 
correction  of  the  anatomic  lesions. 

Every  one  suffers  at  times  from  indigestion  due  to  in- 
discretions in  eating,  but  no  one  has  constant,  persistent 
dyspepsia  lasting  for  months  or  years  unless  it  be  due  to 
some  organic  disease.  A  case  of  indigestion  ought  not  to 
be  subjected  to  surgery  until  it  has  been  carefully  and 
properly  treated  by  medical  measures,  but  every  case  that 
fails  to  secure  relief  in  a  reasonable  time  should  be  exam- 


*  Read  at  the  meeting  of  the  Medical  Association  of  the  State 
of  Alabama,  Montgomery,  Ala.,  April,  191 1. 

87 


THE  SURGICAL  TREATMENT  OF  DYSPEPSIA 

ined  to  see  if  there  is  not  some  indications  for  operative 
intervention. 

In  investigating  a  patient  it  should  be  remembered  that 
while  the  symptoms  may  be  due  to  disease  of  the  stomach 
itself  they  may  also  be  due  to  reflex  irritation  from  dis- 
ease of  some  other  abdominal  organ.  It  is  a  fact  that  in 
nine  cases  out  of  ten  it  will  be  found  that  the  lesion  is  not 
in  the  stomach  but  in  some  associated  viscus,  such  as  the 
duodenum,  appendix  or  gall-bladder.  In  other  words, 
while  the  symptoms  are  gastric  and  the  treatment  is  sur- 
gical the  operation  required  is  not  necessarily  on  the 
stomach. 

Appendicitis,  cholecystitis  and  duodenal  ulcer  are  sup- 
posed to  interfere  with  digestion  by  causing  a  spasm  of 
the  pylorus.  Pylorospasm  is  a  protective  effort  on  the 
part  of  nature  to  prevent  the  passage  of  irritating  gas- 
tric contents  into  the  intestinal  tract.  The  most  promi- 
nent symptom  is  a  cramping  pain  in  the  epigastrium 
which  may  last  only  a  few  minutes  or  may  continue  sev- 
eral hours.  In  some  cases  the  spasm  may  relax  suddenly, 
in  others  it  may  terminate  slowly  and  gradually.  Some 
patients  have  attacks  several  times  a  day,  others  at  in- 
tervals of  weeks,  and  others  still  only  once  or  twice  a 
year.  In  the  interval  between  attacks  digestion  may  be 
normal.  During  attacks  the  peristalsis  of  the  stomach  is 
increased,  but  food  cannot  pass  through  the  pylorus  and 
often  relief  comes  only  after  vomiting.  Pylorospasm  is 
a  symptom,  not  a  disease.  It  is  usually  the  expression  of 
disease  of  some  remote  abdominal  structure.  To  effect  a 
cure  the  real  cause  of  the  condition  must  be  removed,  and 
the  patient  treated  until   the  hypersensitiveness  of   the 

88 


THE   SURGICAL  TREATMENT  OE  DYSPEPSIA 

pyloric  muscle  is  relieved  and  its  spasm  habit  overcome. 

The  essential  role  which  surgery  plays  in  the  successful 
treatment  of  the  various  forms  of  so-called  chronic  dys- 
pepsia will  be  impressed  by  a  brief  review  of  the  symp- 
toms of  duodenal  ulcer,  infection  of  tlie  bile  tract,  chronic 
appendicitis  and  gastric  cancer. 

Duodenal  Ulcer,  while  formerly  thought  to  be  rare, 
is  now  known  to  be  a  very  common  disease.  Patients 
give  a  history  of  indigestion  of  many  years  standing  with 
intervals  of  complete  relief  from  symptoms.  At  first 
there  is  the  development  of  a  sense  of  weight,  oppression 
and  distension  after  meals.  Later  it  is  noted  that  dis- 
comfort occurs  regularly  from  two  to  three  hours  after 
taking  food.  Pain  comes  on  gradually,  and  slowly  in- 
creases. There  is  a  sensation  of  fullness  followed  by 
eructation  of  gas  or  bitter  fluid.  Symptoms  are  imme- 
diately and  completely  relieved  by  taking  food,  and 
patients  frequently  keep  a  biscuit  or  glass  of  milk  easily 
accessible  in  order  to  arrest  the  ''hunger  pain"  when  it 
develops.  A  characteristic  feature  of  duodenal  ulcer  is 
the  recurrence  of  symptoms  after  intervals  of  complete 
relief.  Attacks  come  on  as  the  result  of  exposure  to 
cold,  imprudence  in  eating,  worry,  or  over  work.  The 
physical  signs  consist  in  some  tenderness  in  the  epigas- 
trium and  rigidity  of  the  right  rectus  muscle.  In  the 
later  stages  when  stenosis  develops  there  are  the  signs  of 
dilated  and  obstructed  stomach.  Still  later  there  may  be 
hemorrhage,  the  blood  appearing  in  either  vomitus  or 
feces.  Hemorrhage  is  usually  a  late  symptom.  It  is  an  evi- 
dence of  deep  penetration  of  the  walls  of  the  duodenum 

89 


THE  SURGICAL  TREATMENT  OF  DYSPEPSIA 

by  an  ulcer  whose  existence  should  have  been  recognized 
by  other  symptoms  at  an  earlier  period. 

Chronic  Cholecystitis,  with  or  without  gall  stones,  is 
another  common  cause  of  indigestion.  Symptoms  during 
the  early  stage  of  the  disease  are  always  referred  to  the 
stomach.  There  is  usually  gastric  distress  coming  on 
shortly  after  taking  food  and  relieved  by  eructation  of 
gas.  Frequently  there  is  nausea  and  vomiting  attended 
by  a  dull  pain  beginning  in  the  epigastric  region  and  ex- 
tending around  the  right  side  at  the  level  of  the  tenth  rib. 
Later  there  may  be  typical  attacks  of  biliary  colic.  The 
pain  is  sudden  in  its  onset  and  sudden  in  its  relief,  and  is 
attended  by  a  sharp  catch  in  the  breath.  It  is  cramp 
like,  goes  through  to  the  back  and  up  to  the  right  shoulder 
blade.  The  pain  is  not  produced  nor  is  it  relieved  by 
taking  food.  It  is  attended  by  nausea,  retching  and  vomit- 
ing, and  followed  by  sweating  and  prostration.  Still 
later  there  may  come  the  symptoms  of  duct  obstruction 
with  jaundice,  or  duct  infection  with  chronic  pancreatitis. 
Jaundice  is  not  present  in  50  per  cent,  of  cases  and  its 
absence  should  not  prevent  a  proper  diagnosis. 

Chronic  Appendicitis  may  exist  for  years  and  cause  no 
symptoms  except  dyspepsia.  The  patient  has  no  pain  or 
tenderness  at  McBurney's  point,  but  suffers  with  acid 
stomach,  eructation  of  gas  and  occasional  vomiting.  The 
symptoms  come  on  after  eating  but  there  is  no  regularity 
as  one  meal  may  cause  trouble  while  another  produces  no 
ill  effect.  Food  never  gives  relief  and  exercise  usually 
makes  the  symptoms  worse.  After  a  longer  or  shorter 
time  there  comes  an  acute  attack  of  appendicitis  with 
symptoms  which  make  the  diagnosis  evident.    An  opera- 

90 


THE  SURGICAL  TREATMENT  OF  DYSPEPSIA 

tion  is  done  to  save  the  patient's  ilfe  and  six  months  later 
the  individual  comes  back  to  say  you  have  restored  his 
health.  The  removal  of  the  appendix  has  cured  his  dys- 
pepsia and  he  is  able  to  eat  what  he  pleases  with  im- 
punity. 

Cancer  of  the  Stomach  usually  develops  at  the  seat  of 
and  old  ulcer.  A  careful  investigation  of  the  patient's 
symptoms  will  usually  show  history  of  indigestion  ex- 
tending over  many  years,  first  characteristic  of  hyper- 
chlorhydria,  then  of  gastric  ulcer  and  finally  of  cancer  of 
the  stomach.  There  is  first  indigestion  with  sour 
eructation  and  pain  two  to  five  hours  after  eating. 
Later  vomiting  of  bitter  acid  fluid,  constant  discomfort 
or  distress  and  intense  pain  immediately  after  eating. 
Finally  obstructive  symptoms  with  vomiting  of  retained 
food  mixed  with  blood.  There  is  progressive  weakness, 
emaciation  and  cachexia.  In  the  last  stages  there  is  usu- 
ally the  presence  of  a  palpable  tumor. 

The  foregoing  histories  cover  a  host  of  cases  treated 
by  the  general  practitioner  for  gastralgia,  chronic  gas- 
tritis, sour  stomach  or  acid  dyspepsia.  They  are  definite 
surgical  diseases  and  should  be  recognized  as  such. 

Spasmodic  obstruction  of  the  pylorus,  or  pylorospasm, 
due  to  reflex  irritation  from  chronic  disease  of  the  appen- 
dix or  gall-bladder  should  be  relieved  by  removing  the 
cause,  not  by  an  operation  on  the  stomach  itself. 

Organic  obstruction  of  the  pylorus  from  cicatricial 
contraction  of  an  ulcer  of  the  stomach  or  duodenum 
should  be  relieved  by  the  provision  of  a  new  outlet  by 
means  of  a  gastro-enterostomy. 

91 


THE   SURGICAL  TREATMENT  OF  DYSPEPSIA 

Non-obstructing  ulcers  and  early  carcinomas  of  the 
stomach  should  be  removed  by  resection. 

I  trust  the  views  expressed  will  not  be  considered  too 
radical.  None  of  them  are  original  but  are  a  compilation 
from  the  writings  of  men  of  experience  and  authority. 
With  increasing  knowledge  of  disease  from  observations 
made  by  surgeons  during  operations,  from  investigations 
conducted  by  scientists  in  laboratories,  and  from  deduc- 
tions made  by  internists  from  patients  in  actual  practice, 
we  find  our  views  as  to  the  proper  treatment  of  certain 
conditions  rapidly  changing. 

Today  ex-ophthalmic  goitre  or  hyperthyroidism  is  con- 
sidered a  surgical  affection.  I  feel  sure  in  time  it  will 
be  transferred  to  the  department  of  internal  medicine. 
Until  recently  dyspepsia  has  been  treated  medically.  I 
feel  sure  the  conscientious  physician  will  soon  refer  all 
cases  which  resist  a  reasonable  amount  of  treatment  to 
the  surgeon. 

Conclusions. 

1.  Persistent  or  recurring  indigestion  is  not  due  to 
errors  of  secretion  but  to  anatomical  lesions  of  the 
stomach  or  associated  viscera. 

2.  A  patient  who  is  not  relieved  in  a  reasonable  time 
by  medical  treatment  should  have  the  abdomen  opened 
even  if  the  operation  is  in  the  nature  of  an  exploration. 

3.  While  the  symptoms  are  gastric  in  nine  cases  out 
of  ten  the  lesion  will  not  be  found  in  the  stomach  but 
in  an  associated  viscus  such  as  the  duodenum,  gall-blad- 
der or  appendix. 

4.  Pylorospasm  should  not  be  treated  by  a  gastroen- 

92 


THE  SURGICAL  TREATMENT  OF  DYSPEPSIA 

terostomy  but  by  an  effort  to  diagnosticate  and  remove 
the  irritation  which  produced  it. 

5.  It  is  advisable  at  the  time  of  the  operation  to  ex- 
amine all  abdominal  organs  and  correct  every  abnor- 
mality lest  the  obvious  may  not  be  the  real  cause  of  the 
symptoms. 

6.  It  is  important  that  these  cases  should  have  proper 
post-operative  and  post-hospital  treatment. 


93 


Analysis    of    the    Last    Five    Hundred 

Cases  of  Appendicitis  Operated  On 

at  St.   Luke's  Hospital* 

I  have  no  apologies  to  make  for  reading  a  paper  on 
appendicitis,  because  the  disease  is  so  frequent  as  to 
necessitate  approximately  one-third  of  all  the  abdominal 
section  done,  and  because,  too,  it  is  so  many-sided  as  to 
constantly  present  new  features  for  discussion.  I  must 
apologize,  however,  at  the  very  outset,  for  the  personal 
character  of  this  paper.  It  is  not  a  review  of  the  litera- 
ture of  the  subject,  but  a  statement  of  observations  and 
conclusions  based  upon  my  own  work.  xA.t  another  place 
and  to  other  audiences,  I  might  be  thought  to  be  ego- 
tistical, but  here  among  my  friends,  many  of  whom  have 
brought  me  the  cases  reported,  I  trust  the  spirit  in  which 
I  write  will  not  be  misunderstood.  As  a  further  extenu- 
ating circumstance,  I  would  say  that  this  is  the  first  paper 
on  appendicitis  I  have  ever  read  before  this  or  any  other 
Society. 

Surgically  speaking,  appendicitis  and  I  are  about  the 
same  age.  I  saw  my  father  open  a  "perityphlitic  abscess" 
in  1886,  and  was  his  assistant  in  the  seventeen  operations 
which  formed  the  basis  of  his  original  contributions  to 
the  literature  of  the  subject.    For  the  past  sixteen  years  I 


*  Read  at  meeting  of  the  Medical  Society  of  Virginia,  Chase 
City,  Va.,  November,  1907. 

95 


ANALYSIS   OF   LAST   FIVE   HUNDRED   CASES 

have  operated  on  a  progressively  increasing  number  of 
cases,  but  I  have  avoided  the  subject  in  my  writings,  be- 
cause my  views  as  to  the  treatment  of  certain  types  of 
the  disease  have  several  times  changed,  and  I  have  hesi- 
tated to  put  myself  on  record  until,  by  the  careful  study 
of  a  large  number  of  cases,  I  could  satisfy  myself  of  the 
correctness  of  my  conclusions. 

The  five  hundred  cases  of  appendicitis  which  form 
the  text  of  this  article  were  all  operated  on  at  St.  Luke's 
Hospital,  and  cover  a  period  of  about  five  years'  work. 
The  figures  given  have  been  tabulated  by  one  of  my 
assistants.  Dr.  LaRoque,  and  I  wish  here  to  acknowledge 
my  indebtedness  to  him  for  his  accurate  and  laborious 
work.  They  are  not  selected  cases,  but  are  taken  con- 
secutively from  the  records  of  the  institution,  and  there- 
fore represent  the  disease  as  it  occurs  in  this  section  of 
the  country. 

These  cases  do  not  include  the  removal  of  325  normal 
appendices,  which  were  done  in  the  course  of  operations 
for  other  troubles  in  the  abdomen  during  the  same  period 
of  time.  There  was  no  death  in  this  list  of  cases,  but  it 
does  not  seem  fair  to  include  them,  for  while  it  is  true 
they  were  operations  of  appendectomy,  the  patients  were 
not  suffering  from  appendicitis.  Nor  does  the  list  em- 
brace cases  of  appendicitis  done  during  the  same  period 
at  the  Virginia  Hospital  and  other  institutions,  because, 
first,  of  lack  of  accurate  case  records,  and,  second,  a  desire 
to  cover  a  considerable  working  period,  so  as  to  contrast 
the  results  obtained  under  the  old  methods  with  those  of 
more  recent  adoption. 

In  order  to  facilitate  the  study  of  the  cases  reported, 

96 


OF  APPENDICITIS  AT   ST.  LUKES   HOSPITAL 

it  is  necessary  to  classify  them,  and  I  have  divided  them, 
not  on  a  pathological,  but  on  a  surgical,  basis.  I  have 
separated  them  into  four  classes,  which  I  always  have  in 
mind  when  I  am  deciding  what  to  do  for  a  patient  suf- 
fering with  the  disease. 

1.  Chronic  appendicitis,  where  the  operation  is  done 
between  attacks,  and  the  diagnosis  is  based  on  the  history 
of  the  patient,  tenderness  over  the  appendix,  and,  per- 
haps, digestive  disturbances. 

2.  Acute  appendicitis,  where  the  operation  is  done 
early,  before  inflammation  extends  to  adjacent  structures, 
whether  the  attack  be  primary  or  an  exacerbation  of 
symptoms  during  the  course  of  chronic  disease. 

3.  Appendicitis  zvith  abscess,  or  a  localized  collection 
of  pus  in  the  lower  right  quadrant  of  the  abdomen.  These 
cases  are  again  subdivided  into : 

(a)  Abscesses  which  are  adherent  to  the  parietal  peri- 
toneum and  can  be  opened  and  evacuated  without  infect- 
ing the  general  cavity ; 

(b)  Abscesses  which  are  not  adherent  to  the  abdomi- 
nal wall  and  can  only  be  approached  by  opening  the  gen- 
eral peritoneum. 

4.  Appenicitis  with  diffuse  peritonitis,  where,  owing  to 
the  acuteness  of  the  infection  or  the  absence  of  resistence, 
there  is  no  wall  of  lymph  or  adherent  bowel  and  omen- 
tum to  confine  the  pus,  but  it  finds  its  way  into  the  gen- 
eral peritoneal  cavity. 

Under  this  classification,  the  five  hundred  cases  divide 
themselves  as  shown  in  the  following  table : 

97 


ANALYSIS    OF   LAST   FIVE   HUNDRED    CASES 

Number.  Deaths. 

1.  Chronic  appendicitis  (interval  operation)  . .         177  o 

2.  Acute  appendicitis    (early  operation) 206  i 

3.  Appendicitis  with  abscess : 

(a)  Adherent  to  peritoneum  beneath  in- 

cision           23  o 

(b)  Not  adherent  to  peritoneum  beneath 

incision  .  .  . /O  7 

4.  Appendicitis  with  diffuse  peritonitis 24  6 

Totals 500  14 

Race. — St.  Luke's  Hospital  does  not  receive  colored 
patients,  and  no  record  of  the  nationality  of  the  white 
patients  was  kept;  hence  on  this  subject  the  statistics  are 
valueless.  It  is  a  fact  that  appenicitis  is  not  common 
among  the  negroes ;  still,  during  the  same  working  period, 
I  am  sure  I  have  operated  on  more  than  fifty  cases  in  this 
race  at  another  hospital. 

Age. — The  oldest  patient  in  the  series  reported  was 
seventy-two,  and  the  youngest,  six  years  old.  A  casual 
inspection  of  the  figures  giving  the  ages  of  all  the  patients 
shows  that  appendicitis  is  not  common  at  either  of  the 
extremes  of  life.  It  is  comparatively  rare  in  infants  and 
young  children  on  account  of  the  funnel-shape  structure 
of  the  appendix  and  caecum,  and  relatively  uncommon  in 
old  age  because  the  lymphoid  structure  in  the  appendix 
atrophies  just  as  it  does  in  the  tonsils.  The  mortality 
of  the  disease  in  the  young  is  high,  due  probably  to 
to  their  small  omentum  and  intolerance  to  infection.  In 
the  above  cases  there  are  thirty-eight  occurring  in  chil- 
dren— twenty  attended  by  perforation,  of  which  four 
died.  Thus,  of  the  fourteen  deaths  in  five  hundred  cases, 
four  occurred  in  thirty-eight  operations  on  children. 

98 


OF  APPENDICITIS   AT   ST.   LUKES   HOSPITAL 

Sex. — Of  the  five  hundred  cases,  two  hundred  and 
eight  were  males  and  two  hundred  and  ninety-two  fe- 
males. This  would  seem  to  show  that  women,  despite 
the  additional  blood  supply  to  the  appendix  through  the 
appendiculo-ovarian  ligament  of  Clado,  have  no  relative 
immunity  to  the  disease,  as  compared  to  men,  but,  on  the 
contrary,  are  more  predisposed  to  the  disease,  probably 
from  the  fact  of  the  relation  of  the  appendix  to  the  right 
tube  and  ovary,  and  its  liability  to  infection  from  that 
source.  An  analysis  of  the  figures  shows,  however,  that 
appendicitis  is  more  apt  to  assume  a  fatal  form  in  men 
than  in  women,  for,  despite  the  greater  number  of  cases 
occurring  in  women,  there  were  only  five  deaths,  whereas, 
in  the  smaller  number  of  cases  occurring  in  men,  there 
were  nine  deaths.  The  fact  that  appendicitis  is  more  fatal 
in  one  sex  than  the  other  is  believed  to  be  due  not  only  to 
the  additional  blood  supply  of  the  appendix  in  the  female, 
to  which  attention  has  been  already  called,  but  also  to 
the  fact  that  through  hereditary  immuntiy  they  have 
greater  resistance  to  peritoneal  infection  of  the  lower 
abdomen. 

Mortality. — In  the  500  operations  reported  there  have 
occurred  fourteen  deaths.  This  gives  a  mortality  of  2.8 
per  cent.  Of  the  deaths,  five  occurred  in  the  first  hun- 
dred ;  five  in  the  second  hundred ;  two  in  the  third  hun- 
dred ;  one  in  the  fourth  hundred,  and  one  in  the  fifth 
hundred.  If  it  were  my  purpose  in  this  paper  to  show 
a  low  mortality,  I  would  have  only  reported  the  last  two 
hundred  consecutive  cases,  and  claimed  a  death  rate  of 
one  per  cent.  I  have  purposely  gone  back  in  my  records 
and  included  cases  operated  upon  as  much  as  five  years 

99 


ANALYSIS   OF   LAST   FIVE   HUNDRED   CASES 

ago,  in  order  to  show  the  improvement  which  has  fol- 
lowed the  adoption  of  more  recent  methods  of  operating. 
A  surgeon  should  not  try  to  be  a  record  maker,  but  a  life 
saver,  and  his  ability  should  not  be  reckoned  by  the  cases 
he  loses,  but  the  cases  he  saves.  The  five  hundred  cases 
reported  are  not  selected,  but  are  taken  consecutively  from 
the  hospital  records.  During  the  working  period  covered, 
every  case  admitted  was  operated  on  except  one,  who 
was  moribund  when  first  seen  and  died  two  hours  later. 
The  rapidly  decreasing  mortality  in  the  series  of  cases 
will  be  partly  explained  when  I  describe  the  change 
adopted  in  the  technique  of  operating  on  certain  types, 
but  also  has  explanation  in  the  education  of  the  pro- 
fession and  public  as  to  the  advisability  of  early  opera- 
tion, and  the  greater  promptness  with  which  a  case  is 
now  brought  to  the  surgeon.  It  is  an  unquestioned  fact 
that  the  results  obtained  in  operating  for  appendicitis 
depend  not  as  much  upon  the  skill  of  the  operator  as  the 
conditions  and  the  complications  with  which  he  has  to 
deal. 

Symptoms  and  Diagnosis. — On  this  subject  I  have 
little  to  say.  When  the  clinical  history  and  symptoms 
are  typical,  there  is  no  difficulty  in  making  a  positive 
diagnosis.  When  the  classical  signs  are  absent,  it  is  often 
impossible  to  say  that  appendicitis  does  not  exist.  In 
other  words,  in  these  five  hundred  cases,  I  have  never 
failed  to  find  the  appendix  inflamed  when  I  have  made 
a  preliminary  diagnosis  of  appendicitis,  and  I  have  often 
found  it  to  exist  when  I  had  not  made  a  postive  diagnosis, 
but  did  an  exploratory  operation,  like  Elbert  Hubbard 
sends  a  new  book — "on  suspicion." 

JOG 


OF  APPENDICITIS  AT   ST.  LUKES   HOSPITAL 

Treatment. — It  is  now  a  generally  conceded  fact  that 
there  is  but  one  treatment  for  appendicitis — namely,  the 
surgical  removal  of  the  diseased  organ.  The  question 
that  has  perplexed  the  profession  is  when  to  operate. 
For  a  long  time  I  held  the  opinion  that  no  fixed  rule  could 
be  formulated  and  that  every  case  should  be  decided  on 
its  own  mtrt.  I  then  became  a  follower  of  Ochsner,  and 
claimed  that  some  cases  came  to  the  surgeon  too  late  for 
an  early  operation,  and  too  early  for  a  late  operation, 
and  that  an  effort  should  be  made  to  carry  them  over 
this  period  by  gastric  lavage,  prohibition  of  food  by  the 
mouth,  and  nourishment  by  the  rectum.  Finally,  how- 
ever, after  much  thought  and  careful  observation,  I  have 
become  firmly  convinced  that  Murphy  was  right  in  his 
bold  and  dogmatic  statement  made  many  years  ago,  that 
we  should  operate  on  all  cases  of  appendicitis  as  soon  as 
the  diagnosis  is  made.  There  are,  of  course,  a  few  cases 
where  this  rule  will  work  hardship,  but  I  am  sure  that 
if  it  is  rigidly  applied,  it  will  accomplish  "the  greatest 
good  to  the  greatest  number,"  and  that  the  man  who 
follows  it  will,  in  the  end,  save  more  patients  than  the 
one  who  does  not.  The  objections  made  to  it  are  that 
we  should  not  operate  upon  the  convalescent  or  the 
moribund.  The  answer  is  that  it  is  impossible  to 
differentiate  between  them  and  the  others.  Patients 
apparently  improving  and  on  the  road  to  recovery  some- 
times develop  a  fatal  complication,  and  patients  ap- 
parently dying  sometimes  get  well  by  means  of  a  timely 
operation  performed  by  a  courageous  surgeon. 

The  question  with  me  is  no  longer  when  to  operate. 
It  is  settled,  and  I  am  as  free  from  doubts  and  misgivings 
and  as  happy  in  the  conviction  of  the  truth  of  my  doc- 

lOI 


ANALYSIS   OF   LAST   FIVE   HUNDRED   CASES 

trine  as  an  erring  darky  who  has  been  long  seeking  and 
suddenly  found  religion.  The  question  now  with  me  is 
how  to  operate,  and  I  think  this  can  only  be  determined 
by  dividing  cases  into  certain  groups  and  applying  a  dif- 
ferent method  to  each. 

1.  Chronic  appendicitis,  where  the  operation  is  done 
between  attacks,  the  patient  being  well,  and  the  diagnosis 
based  on  previous  history,  tenderness  over  the  appendix, 
and  perhaps  digestive  disturbances.  The  technique  of 
an  operation  on  this  type  of  appendicitis  is  not  of  much 
moment.  Personally,  I  use  McBurney's  muscle  splitting 
incision,  deliver  the  csecum  into  the  wound,  and  ligate 
and  divide  the  mesentery  of  the  appendix.  I  then  crush 
the  base  of  the  appendix,  tie  it  with  catgut,  amputate 
and  bury  the  stump  with  a  purse-string  suture  of  linen. 
I  then  close  the  peritoneum  and  the  two  muscular  layers 
of  the  abdominal  wall  with  catgut,  and  sew  the  skin  and 
underlying  fat  with  horse-hair.  If  no  complications 
exist,  the  time  of  the  operation  is  from  five  to  seven 
minutes;  the  length  of  the  incision  from  two  to  three 
inches ;  confinement  in  bed,  ten  to  fourteen  days ;  and 
detention  from  business,  two  to  three  weeks.  I  have 
never  had  a  hernia  or  death  following  an  operation  of 
this  type.  It  is  one  of  the  safest  and  most  satisfactory 
in  surgery,  not  only  removing  danger  of  a  subsequent 
attack  of  appendicitis,  but  frequently  relieving  long- 
standing digestive  disturbances  and  causing  marked  im- 
provement in  the  patient's  general  health. 

2.  Acute  appendicitis,  where  the  operation  is  done 
before  inflammation  extends  to  adjacent  structures. — The 
technique  in  this  class  of  cases  is  exactly  the  same  as 
the  foregoing.    It  is  necessary  to  work  more  slowly  and 

102 


OF  APPENDICITIS   AT   ST.   LUKES   HOSPITAL 

handle  the  appendix  more  carefully,  in  order  to  avoid 
rupture  of  its  walls  and  infection  of  the  peritoneal  cavity. 
There  is  no  necessity  for  the  use  of  drainage,  and  re- 
covery is  as  prompt  as  in  chronic  cases.  The  only  death 
I  have  had  in  the  two  hundred  and  six  cases  of  the 
present  series  was  due  to  an  error.  The  patient  was  a 
young  man  just  recovering  from  an  attack  of  appendicitis 
which  had  confined  him  to  bed  for  two  weeks.  He  had 
stricture  of  the  urethra,  for  which  an  operation  had  been 
done  by  another  surgeon.  Before  taking  the  anaesthetic, 
he  asked  that  while  on  the  table  the  stricture  be  well 
dilated.  The  appendix  was  found  congested  and  ad- 
herent, but  was  removed  without  difficulty.  After  the 
abdominal  dressings  were  applied,  a  large  sound  was 
introduced  into  the  urethra.  He  did  well  for  some  hours, 
then  had  a  hard  chill,  developed  septicemia,  and  died 
within  forty-eight  hours.  As  stated,  the  appendectomy 
in  this  case  was  an  uncomplicated  one;  and  four  other 
abdominal  sections  done  the  same  day,  with  the  same 
instruments  and  the  same  assistants,  made  uneventful 
recoveries.  I  sincerely  believe  the  man's  death  was  due 
to  the  urethral  instrumentation,  but  as  the  primary 
operation  was  for  appendicitis,  the  result  is  classed  under 
that  head. 

3.  Appendicitis  with  abcess. — The  technique  of  opera- 
tions for  this  type  depends  entirely  upon  whether  the 
abcess  is  adherent  to  the  abdominal  wall  and  can  be  in- 
cised and  drained  without  opening  the  peritoneal  cavity, 
or  whether  it  is  not  adherent  and  can  only  be  reached 
by  opening  the  general  peritoneum. 

(a)  If  the  abcess  is  adherent  to  the  parietal  peri- 
toneum beneath  the  incision,  it  should  simply  be  opened 

103 


ANALYSIS   OF   LAST   FI\^   HUNDRED   CASES 

and  drained,  and  no  effort  made  to  locate  or  remove  the 
diseased  appendix.  W^ith  all  due  deference  to  those  who 
do  not  agree  with  me,  I  consider  it  a  surgical  crime  to 
break  up  the  protecting  wall  formed  by  nature,  and  to 
liberate  infectious  fluid  into  the  peritoneal  cavity,  when 
a  safe  exit  may  be  given  the  pus  by  simply  following  the 
indication  of  nature  and  making  an  incision  at  the  point 
she  is  endeavoring  to  effect  drainage.  The  only  danger 
in  adopting  this  method  is  that  there  may  be  a  secondary 
abcess  which  will  not  be  drained.  This  complication 
should  always  be  borne  in  mind,  especially  when  the 
patient  has  been  sick  many  days.  If  a  second  collection 
of  pus  is  detected,  the  case  should  be  treated  as  will  be 
described  in  the  next  class. 

The  safety  of  the  operation  advocated  is  shown  by 
the  fact  that  of  the  twenty-three  cases  above  reported 
there  were  no  deaths.  In  all  these  cases  the  patients  were 
told  that  they  were  operated  on  not  for  appendicitis,  but 
for  an  abcess  which  was  the  result  of  appendicitis,  and 
that  their  appendix  had  not  been  removed.  They  were 
advised  of  the  possibility  of  future  trouble  and  warned 
to  apply  promptly  for  surgical  relief  if  in  the  future  they 
suffered  abdominal  pain.  As  far  as  I  know,  there  has 
been  no  subsequent  trouble  in  any  of  the  twenty-three 
cases. 

(b)  If  the  abcess  is  not  adherent  to  the  peritoneum 
beneath  the  incision,  but  is  between  the  walls  of  the 
intestines  or  folds  of  the  omentum,  in  a  position  in  which 
it  can  only  be  reached  after  opening  the  general  peritoneal 
cavity,  then  an  entirely  different  technique  must  be  pur- 
sued. After  the  abdomen  is  opened  and  the  inflammatory 
mass   located   by   palpation   it   should   be   carefully   and 

104 


OF  APPENDICITIS  AT   ST.   LUKES   HOSPITAL 

effectually  isolated  from  adjacent  structures  by  numerous 
pads  of  gauze  wrung  out  of  hot  saline  solution.  Adhe- 
sions should  then  be  separated,  until  the  pus  collection 
is  opened.  It  should  be  sponged  out  and  the  appendix 
sought  for  and  removed.  The  infected  area  should  then 
be  drained  with  strips  of  gauze  enclosed  in  a  protecting 
layer  of  rubber  tissue.  One  end  of  the  drain  should  cover 
the  denuded  surface  in  the  peritoneal  cavity;  the  other 
should  project  through  the  upper  angle  of  the  abdominal 
incision.  In  addition  to  this,  a  rubber  tube  should  be 
inserted  through  the  lower  angle  of  the  incision  so  as  to 
drain  the  bottom  of  the  pelvis,  and  the  patient  should 
be  put  to  bed  in  an  exaggerated  Fowler's  position. 

In  the  five  hundred  cases  recorded,  seventy  were  of 
this  type,  giving  seven  deaths,  or  a  mortality  of  lo  per 
cent.  Most  of  the  fatal  cases  occured  before  the  use  of 
the  pelvic  drainage  and  Fowler's  position,  and  in  future 
it  is  believed  results  will  be  much  better. 

4.  Appendicitis  with  diffuse  peritonitis,  or  cases  where 
there  is  perforation  of  the  appendix  and  free  pus  in  the 
general  peritoneal  cavity.  This  type,  until  recently,  has 
been  the  terror  of  the  surgeon.  The  old  method  of  open- 
ing the  abdomen,  removing  the  appendix,  washing  out  the 
peritoneal  cavity  with  or  without  evisceration,  and  making 
counter  incisions  for  multiple  drainage,  was  followed 
by  a  mortality  of  about  80  per  cent.  There  has  been, 
to  my  mind,  no  recent  advance  in  surgery  so  brilliant  in 
theory  or  so  practical  in  results  as  the  new  technique  of 
treating  diffuse  suppurative  peritonitis.  In  these  cases 
a  short  incision  should  be  made  over  the  appendix,  and 
the  diseased  organ  removed,  if  it  is  readily  accessible. 
A  second  incision,  not  necessarily  more  than  an  inch  in 

105 


ANALYSIS    OF   LAST   FIVE   HUNDRED    CASES 

length,  should  be  made  in  the  mid-line,  above  the  pubes. 
A  rubber  tube  one-half  inch  in  diameter,  with  openings 
on  the  side,  should  be  introduced  through  the  suprapubic 
opening  and  carried  to  the  bottom  of  the  pelvis.  No 
irrigation  of  the  abdomen  should  be  practiced,  no  effort 
even  made  to  sponge  out  the  pus,  but  a  voluminous  dress- 
ing should  be  applied  and  the  patient  quickly  put  to  bed 
in  an  exaggerated  Fowler's  position.  Saline  solution 
should  be  slowly  and  continuously  given  by  rectum,  the 
stomach  contents  washed  out  if  vomiting  is  persistent, 
and  the  heart  and  kidneys  stimulated  by  the  hypodermic 
use  of  sulphate  of  spartine  in  large  doses. 

The  difficulty  often  experienced  is  to  keep  the  patient 
in  the  proper  position  in  bed,  so  that  fluids  in  the  abdomi- 
nal cavity  will  be  carried  by  gravity  to  the  pelvis.  To 
obviate  this,  I  have  devised  a  bed-seat,  which  is  easily 
and  cheaply  constructed  and  which  will  maintain  a 
patient,  with  perfect  comfort,  at  any  angle  it  is  desired 
to  elevate  the  head  of  the  bed.     (See  figs,  i,  2,  3.) 

Of  the  twenty-four  cases  of  appendicitis  with  diffuse 
peritonitis  in  the  cases  reported,  there  were  six  deaths. 
Five  of  these  occurred  in  the  first  six  cases  operated  on, 
when  the  method  of  irrigation  and  multiple  drainage  was 
practiced.  Since  the  adoption  of  the  new  method,  two 
years  ago,  I  have  had  but  one  death  in  the  remaining 
eighteen  cases.  In  other  words,  the  change  of  technique 
has  reduced  the  mortality  from  over  80  per  cent,  to  5.5 
per  cent. 


106 


Some     Accepted     Facts     and     Mooted 

Points  in  the   Management 

of  Appendicitis  * 

Before  certain  societies  it  is  both  proper  and  desirable 
that  unusual  cases  should  be  reported,  original  opera- 
tions described,  and  new  theories  advanced,  but  at  a 
meeting  such  as  this,  I  think  the  time  at  our  disposal 
should  be  devoted  to  the  discussion  of  the  diseases  we 
are  most  frequently  called  upon  to  treat ;  and  hence  those 
we  should  endeavor  to  know  most  about.  I  believe  we 
should  recognize  the  fact  that  we  are  practitioners,  and 
not  scientific  investigators,  and  that  we  should  leave  the 
solution  of  new  and  complicated  problems  to  the  men 
working  in  laboratories  and  large  metropolitan  hospitals, 
and  be  satisfied  ourselves  if  we  adopt  the  best  and  most 
accepted  methods,  and  apply  them  skillfully  and  effi- 
ciently for  the  relief  of  our  patients. 

Personally,  entertaining  these  views,  I  am  glad  to 
learn  from  the  program  that  practically  the  entire  time 
of  this  meeting  will  be  devoted  to  the  consideration  of 
appendicitis  and  typhoid  fever.  Those  who  read  papers 
may  have  nothing  essentially  new  to  present,  but  the  same 
may  be  said  of  ministers,  who  have  preached  the  Gospel 
for  many  centuries,  and  whose  labor  is  not  in  vain. 

History. — Appendicitis  was  first  clearly  recognized  and 
accurately  described  by  Fitz,  of  Boston,  in  1886,  and  the 


*  Read  at  meeting  of  the  Florida  State  Medical  Association, 
Pensacola,  Fla.,  April,  1909. 

107 


ACCEPTED  FACTS  AND  MOOTED   POINTS  IN 

profession  of  America  has  been  largely  instrumental  in 
working  out  the  various  problems  with  reference  to  its 
diagnosis  and  treatment.  The  English  and  Continental 
surgeons,  for  a  time,  derisively  called  it  the  American 
disease,  and  were  obstructionists  in  the  advance  of  knowl- 
edge concerning  it,  and  although  they  have  now  fallen 
in  line,  they  have  never  been  able  to  keep  pace  with  the 
work  of  the  profession  in  this  country. 

Frequency. — The  frequency  of  appendicitis  is  shown 
by  the  fact  that,  according  to  Osier,  it  causes  the  death 
of  one  out  of  every  fifty  who  die,  and  by  hospital  records 
which  show  that,  in  recent  years,  it  is  responsible  for 
from  one-fourth  to  one-third  of  all  the  operations  per- 
formed. The  disease,  however,  is  not  as  frequent  as  one 
might  infer  from  the  society  notes  in  a  daily  paper  as, 
from  personal  observation,  I  have  known  many  patients 
to  attribute  confinement  in  a  sanitarium  to  appendicitis, 
when  their  disease  was  in  reality  a  less  interesting  and 
fashionable  ailment.  The  laity  are  under  the  impression 
that  the  number  of  cases  of  appendicitis  is  increasing, 
but  this,  of  course,  is  not  so.  Cases  are  now  correctly 
diagnosticated  as  appendicitis,  whereas,  before  they  were 
called  gastritis,  peritonitis,  and  inflammation  of  the 
bowels.  Robert  Morris  said  that  if  a  torch  were  applied 
to  the  tomb  of  every  man  dying  of  unrecognized  appendi- 
citis, the  world  would  be  a  bon-fire. 

Why  the  disease  was  not  recognised  earlier. — It  seems 
d'fficult  for  us  to-day,  to  understand  how  a  disease  which 
was  so  frequent  could  have  escaped  recognition  by  clini- 
cians of  the  past,  who  were  justly  noted  for  their  ac- 
curacy of  observation.  The  explanation  lies  in  the  fact 
the   symptoms  of  appendicitis,  originating  in  an  organ 

io8 


THE  MANAGEMENT  OF  APPENDICITIS 

without  function,  were  characterized  by  reflex  disturb- 
ances of  the  function  of  other  and  more  important  organs, 
and  hence  were  misconstrued  during  the  life  of  the 
patient.  If  death  ensued  and  a  post-mortem  was  made, 
the  secondary  complications  so  obscured  the  original 
lesion  that  it  was  overlooked.  A  physician  told  me  that 
while  in  New  York  taking  a  post-graduate  course,  in 
1878,  he  saw  a  case  in  the  ward  of  one  of  the  hospitals 
which  was  treated  first  for  gastritis,  then  for  peritonitis, 
and  finally  for  locked  bowel.  When  the  patient  died,  a 
post-mortem  was  made,  and  the  pathologist  commented 
on  the  fact  that  the  inflammation  had  been  so  severe  that 
the  appendix  had  sloughed  off.  Two  years  later,  when 
engaged  in  private  practice,  this  physician  saw  another 
case  die  with  similar  symptoms,  and  before  making  the 
post-mortem,  he  told  his  colleagues  that  he  was  certain 
that  they  would  find  the  appendix  gangrenous,  and  such 
proved  to  be  the  case.  In  neither  instance  did  it  occur 
to  any  of  the  physicians  that  the  condition  of  the  appendix 
was  the  primary  cause  of  the  trouble. 

Living  versus  Dead  Pathology. — Post-mortem  exami- 
nations have,  of  course,  been  of  inestimable  service  in 
increasing  our  knowledge  of  disease,  but  conclusions 
based  on  them  have  often  been  erroneous,  because  they 
are  made  at  a  period  when  secondary  complications  and 
terminal  infections  obscure  the  initial  lesion.  The  patho- 
logic picture  of  the  early  stages  of  disease  as  disclosed 
during  life,  on  the  operating  table,  are  immeasurably 
more  valuable  than  the  findings  after  death,  at  autopsy. 
This  fact  is  apparently  not  appreciated  by  the  physician, 
or  if  it  is,  he  fails  to  take  advantage  of  it.  Many  will 
drive  ten  miles  to  see  a  post-mortem,  who  would  not 

109 


ACCEPTED   FACTS  AND  MOOTED   POINTS   IN 

go  around  the  corner  to  witness  an  ante-mortem  demon- 
stration of  the  same  disease  at  a  more  instructive  stage 
of  its  development.  In  visiting  the  various  surgical  clinics 
of  this  and  other  countries,  I  have  often  deplored  the 
fact  that  they  were  not  attended  more  largely  by  medical 
men.  Last  summer  I  made  a  trip  to  see  work  in  Chicago, 
Rochester,  Cleveland,  Boston  and  New  York.  In  each 
city  I  found  a  number  of  surgeons.  Some  were  young 
and  some  were  old ;  some  were  rich  and  some  were  poor ; 
some  were  famous  and  some  were  unknown.  All  were 
possessed  by  a  desire  to  learn.  I  do  not  recall  meeting 
a  single  physician.  They  must  have  been  either  at  home 
pursuing  their  usual  occupation,  or  at  the  seashore,  in 
the  mountains,  or  abroad,  taking  a  vacation.  It  is  some- 
times said  that  the  professional  and  pecuniary  rewards 
of  the  surgeon  are  greater  than  those  of  the  physician. 
If  this  be  so,  where  lies  the  credit  or  the  blame  of  the 
reversal  of  conditions  previously  existing? 

Operate  in  Every  Case. — The  one  generally  accepted 
fact  in  the  treatment  of  appendicitis  is  that  every  case 
should  be  operated  on.  There  is  a  wide  difference  of 
opinion,  however,  as  to  when  the  operation  should  be 
done,  how  the  various  steps  should  be  performed,  and 
the  way  the  case  should  subsequently  be  treated.  It  is 
admitted  that  many  cases  recover  from  acute  attacks 
under  medical  treatment:  hence  it  is  obvious  that  if 
all  cases  are  operated  on,  some  cases  will  be  subjected  to 
unnecessary  surgery.  Statistics  show  that  in  a  hundred 
cases,  eighty  will  recover  without  the  use  of  the  knife, 
but  they  also  show  that  twenty  will  die.  Of  these  eighty 
who  recover,  many  will  have  recurrent  attacks,  and  most 
of  them  will  suffer   from  digestive  disturbances  which 

no 


THE  MANAGEMENT  OF  APPENDICITIS 

cripple  their  usefulness.  As  it  is  impossible  to  say  from 
the  history,  clinical  symptoms  or  laboratory  findings 
which  cases  need  an  operation,  and  which  do  not,  it  is, 
therefore,  better  to  operate  on  some  who  do  not  require 
it,  than  to  fail  to  operate  on  those  who  urgently  need 
it,  especially  as  the  operation  in  itself  has  practically  no 
mortality.  I  say  this  advisedly,  for  I  do  not  believe  an 
appendectomy  entails  any  more  danger  than  a  trip  on 
the  railway.  There  are,  of  course,  the  danger  of  the 
anesthetic  and  the  risk  of  infection,  but  these,  in  skilled 
hands,  are  accidents  no  more  likely  to  occur  than  catas- 
trophes on  well  regulated  railroads.  Frequently  you  see 
in  the  daily  papers,  and  sometimes  in  medical  journals, 
the  statement  that  a  patient  has  died  on  account  of  an 
operation.  Usually  the  fact  is  that  he  died  from  a  disease 
which  the  operation  failed  to  arrest,  and  frequently  be- 
cause a  surgeon  was  called  in  as  a  last  resort  to  save  life, 
and  not  as  an  early  effort  to  restore  health.  Let  the  pro- 
fession differ  on  other  points,  but  let  it  unite  in  teaching 
the  laity  that  appendicitis  is  a  surgical  disease,  that  every 
case  requires  an  operation,  and  that,  barring  accidents, 
which  occasionally  happen  in  well  regulated  hospitals  as 
well  as  in  well  regulated  families,  there  is  no  danger  in 
surgical  intervention. 

Appendicitis  nozv  a  Question  of  Economics. — Years 
ago,  when  many  cases  of  appendicitis  died  because  opera- 
tions were  postponed  until  the  patient's  condition  was 
hopeless,  the  great  question  with  both  the  profession  and 
the  laity  was  the  mortality.  Later,  when  results  were 
improved,  but  when  operations  were  still  delayed  until 
complications  developed,  and  patients  were  left  with 
crippling  sequelse,  the  question  was  morbidity.     To-day, 

III 


ACCEPTED  FACTS  AND  MOOTED  POINTS  IN 

when  practically  all  cases  recover,  and  are  completely 
restored  to  health,  the  question  is  economy. 

A  patient,  when  informed  that  he  has  appendicitis,  no 
longer  asks  what  is  the  danger  to  his  life,  rarely  discusses 
the  possibility  of  hernia  or  other  complications,  but  wants 
to  know  how  much  the  operation  will  cost  him  in  time 
and  money.  The  question  of  the  length  of  his  stay  in 
the  hospital  depends  largely  upon  whether  it  is  found 
necessary  to  employ  drainage.  The  question  of  the 
amount  of  the  surgeon's  charge  depends  chiefly  on  the 
patient's  ability  to  pay.  It  is  a  fact  that  there  is  no  case 
on  record  where  an  operator  has  declined  to  do  the  work 
without  a  fee  if  the  patient  was  poor,  or  where  he  has 
failed  to  require  a  munificent  sum  if  the  patient  was  rich. 
The  laity  should  be  impressed  with  the  fact  that  a  sur- 
gical fee  covers  three  separate  factors :  First,  the  satis- 
faction of  having  an  operator  of  reputation;  second,  the 
security  of  having  one  with  skill  and  ability;  and  third, 
the  physical  relief  from  the  actual  mechanical  work. 

When  to  Operate. — The  question  of  when  to  operate 
for  appendicitis  will  perhaps  never  be  satisfactorily  set- 
tled. Personally,  I  am  convinced  that  Murphy  was  right 
in  his  bold  and  dogmatic  statement  made  many  years  ago, 
that  we  should  operate  on  all  cases  of  appendicitis  as 
soon  as  the  diagnosis  is  made.  There  are,  of  course,  a 
few  cases  where  this  rule  will  work  hardship,  but  I  am 
sure  that  if  it  is  rigidly  followed,  it  will  accomplish  the 
greatest  good  to  the  greatest  number,  and  that  the  sur- 
geon who  follows  it  will,  in  the  end,  save  more  patients 
than  the  one  who  does  not.  The  objections  made  to  it 
are  that  we  should  not  operate  upon  the  convalescent  or 
the  moribund.     The  answer  is  that  it  is  sometimes  im- 

112 


THE  MANAGEMENT  OF  APPENDICITIS 

possible  to  diagnosticate  these  cases.  Patients  appar- 
ently improving  and  on  the  road  to  recovery  sometimes 
develop  a  fatal  complication,  and  patients  apparently 
dying  sometimes  get  well  by  means  of  a  timely  operation 
performed  by  a  courageous  surgeon. 

Ochsner,  by  his  teaching,  has,  in  my  opinion,  caused 
the  death  of  more  patients  with  appendicitis  than  his  per- 
sonal ability  as  an  operator  has  enabled  him  to  save,  and 
this  not  because  his  teaching  was  wrong,  but  because  it 
has  been  misunderstood,  and  his  treatment  misapplied. 
Ochsner  believes  in  operating  on  all  cases  of  appendicitis, 
but  in  a  certain  class  he  advises  waiting,  employing  gastric 
lavage,  rectal  alimentation,  and  Fowler's  position,  until 
the  inflammation  becomes  localized,  and  the  patient  in  a 
more  favorable  condition  for  surgical  intervention.  Per- 
sonally, I  believe  that  Ochsner's  treatment  will  save  some 
cases  which  would  otherwise  be  lost,  but  despite  this 
fact,  I  am  satisfied  that  it  would  be  better  for  the  pro- 
fession and  for  the  public  if  his  teaching  had  never  been 
disseminated.  It  has  been  seized  upon  by  the  general 
practitioner  as  a  medical  cure  for  appendicitis,  and  has 
been  the  excuse  for  procrastinations  which  has  resulted 
in  many  an  untimely  death. 

How  to  Operate. — An  extremely  important  factor  in 
the  success  of  a  surgeon  in  operating  for  appendicitis  is 
his  ability  to  differentiate  in  cases,  and  to  recognize  the 
fact  that  different  groups  must  be  treated  in  an  entirely 
different  way.  For  practical  purposes,  cases  may  be 
divided  into  three  classes :  First,  those  in  which  the  in- 
flammation is  confined  to  the  appendix;  second,  those  in 
which  the  inflammation  has  extended  beyond  the  appendix 
and  resulted  in  a  localized  abcess ;  and  third,  those  in 

113 


ACCEPTED  FACTS  AND  MOOTED   POINTS  IN 

which  the   inflammation   has  caused   diffuse  peritonitis, 
with  the  presence  of  free  fluid  in  the  abdominal  cavity. 

I.  Chronic  and  Acute  Appendicitis. — In  chronic  ap- 
pendicitis where  the  operation  is  done  between  the  attacks, 
or  in  acute  appendicitis  where  the  operation  is  done  be- 
fore inflammation  extends  to  adjacent  structures,  the 
technique  of  the  operation  is  not  of  much  moment.  The 
differences  of  opinion  which  exist  among  surgeons  are 
with  reference  to  the  location  of  the  incision,  the  treat- 
ment of  the  stump  of  the  appendix,  and  the  length  of 
time  it  is  necessary  to  confine  the  patient  to  bed. 

1.  The  incisions  in  most  common  use  are  a  vertical 
incision  through  the  right  rectus,  or  an  oblique  incision, 
with  separation  of  the  fibres  of  the  external  and  internal 
oblique  muscles  at  right  angles  one  to  the  other.  Either 
method  gives  good  results,  although,  personally,  the  grid- 
iron incision  appeals  to  me  as  the  one  inflicting  less  trau- 
matism, giving  most  direct  access  to  the  field  of  opera- 
tion, and  guaranteeing  the  greatest  assurance  against 
hernia. 

2.  The  methods  of  dealing  with  the  stump  of  the 
appendix  are  endless.  The  two  in  most  frequent  use 
are  simple  ligation,  and  ligation  with  inversion  of  the 
stump  by  means  of  a  purse-string  ligature.  I  usually 
practice  the  latter,  as  I  have  never  experienced  the  com- 
plications believed  by  some  to  be  theoretically  possible 
from  burying  infected  tissue,  and  I  think  the  purse-string 
suture  lessens  the  possibility  of  the  primary  ligature  being 
blown  off  by  gas  pressure,  and  removes  the  probability 
of  adhesions  which  otherwise  might  form  on  a  denuded 
surface. 

3.  The  question  of  the  length  of  time  it  is  necessary 

114 


THE  MANAGEMENT  OF  APPENDICITIS 

to  keep  the  patient  in  bed  after  a  simple  appendectomy 
is  one  of  great  importance.  The  tendency  is  to  make 
the  patient's  stay  in  the  hospital  shorter  and  shorter.  This 
is  partly  due  to  motives  of  economy,  but  is  also  influenced 
by  a  desire  to  advertise  the  surgeon.  Between  too  great 
conservatism  on  the  one  hand,  with  the  attendant  loss 
of  time  and  money,  and  too  great  radicalism  on  the  other, 
with  the  danger  of  hernia  and  other  complications,  there 
must  eventually  be  derived  a  happy  mean.  For  my  own 
satisfaction,  some  time  ago,  I  sent  a  circular  letter  to 
fifty  prominent  surgeons,  asking  the  practice  of  each. 
The  answers  varied  so  widely  as  to  be  practically  worth- 
less, one  stating  that  he  had  patients  walking  about  the 
following  day,  and  another  that  he  kept  them  in  bed  forty- 
two  days.  My  own  custom  is  to  keep  patients  re- 
cumbent ten  days,  allow  them  to  go  about  in  a  wheel 
chair  two  days,  and  to  discharge  them  at  the  end  of  four- 
teen days.  I  heartily  deprecate  the  tendency  to  compe- 
tition which  exists  between  some  surgeons  as  to  who 
can  get  their  cases  out  quickest.  The  laity  and  profession 
ought  to  be  made  to  understand  that,  under  given  cir- 
cumstances, a  wound  will  not  heal  quicker  for  one  opera- 
tor than  for  another,  and  the  length  of  time  it  is  thought 
necessary  to  keep  the  patient  in  bed  is  not  a  measure  of 
surgical  dexterity,  but  of  surgical  judgment. 

II.  Appendicitis  with  Ah  cess. — The  technique  for 
operations  of  this  type  depends  entirely  upon  whether 
the  abcess  is  adherent  to  the  abdominal  wall,  and  can 
be  incised  and  drained  without  opening  the  general  peri- 
toneal cavity,  or  whether  it  is  not  adherent  and  can  only 
be  reached  after  opening  the  general  peritoneum.  If  the 
abcess  is  adherent  to  the  parietal  peritoneum,  it  should 

115 


ACCEPTED  FACTS  AND  MOOTED  POINTS  IN 

simply  be  opened  and  drained,  and  no  effort  made  to 
locate  or  remove  the  diseased  appendix.  With  all  due 
deference  to  those  who  do  not  agree  with  me,  I  consider 
it  a  surgical  crime  to  break  up  the  protecting  wall  and  to 
liberate  infectious  fluid  into  the  peritoneal  cavity,  when 
a  safe  exit  can  be  given  the  pus  by  simply  following  the 
indications  of  nature,  and  making  an  incision  at  the  point 
where  she  is  endeavoring  to  effect  drainage. 

If  the  abcess  is  not  adherent  to  the  peritoneum  beneath 
the  incision,  but  is  located  between  the  folds  of  the  omen- 
tum or  behind  the  csecum,  in  a  position  in  which  it  can 
be  reached  only  by  opening  the  general  peritoneal  cavity, 
then  an  entirely  different  technique  must  be  pursued. 
After  the  abdomen  is  opened  and  the  inflammatory  mass 
located  by  palpation,  it  should  be  carefully  and  effectually 
isolated  from  adjacent  structures  by  numerous  pads  of 
gauze  wrung  out  of  hot  saline  solution.  Adhesions  should 
then  be  separated  until  the  pus  collection  is  opened.  The 
abcess  should  be  gently  sponged  out,  and  the  appendix 
sought  for  and  removed.  The  infected  area  should  be 
drained  with  strips  of  gauze  enclosed  in  a  protecting 
layer  of  rubber  tissue,  and  a  tube  should  be  inserted 
through  the  lower  angle  of  the  wound  to  the  bottom  of 
the  pelvis,  and  the  patient  put  to  bed  in  an  exaggerated 
Fowler's  position. 

When  an  abcess  is  drained  and  the  appendix  not  re- 
moved, the  patient  should  be  told  that  the  operation  was 
not  for  appendicitis,  but  for  an  abcess  which  was  the  re- 
sult of  appendicitis.  He  should  be  made  to  understand, 
that  the  appendix  was  not  removed,  advised  of  the  possi- 
bility of  future  trouble,  and  warned  to  apply  promptly 
for  surgical  relief  if  he  suffered  abdominal  pain. 

ii6 


THE  MANAGEMENT  OF  APPENDICITIS 

I  have  recently  had  correspondence  with  a  number  of 
prominent  surgeons  to  ascertain  their  views  as  to  the 
necessity  for  a  second  operation  for  the  removal  of  the 
appendix  left  in  the  abdomen  at  a  first  operation.  I  have 
secured  a  large  number  of  opinions,  and  find  that  while 
all  agree  that  the  organ  should  be  removed  if  it  causes 
symptoms,  they  are  about  equally  divided  as  to  the  wis- 
dom of  operating  on  every  case  as  a  routine  method.  As 
an  example  of  the  divergent  views,  I  will  cite  Dr.  J. 
M.  T.  Finney,  of  Baltimore,  who  writes  that  in  all  cases 
of  abcess  treated  by  simple  incision  and  drainage,  he  ear- 
nestly advises  a  secondary  operation  for  the  removal  of 
the  appendix.  He  was  forced  to  this  opinion  by  seeing 
three  cases  of  death  during  secondary  attacks  of  appendi- 
citis after  an  appendiceal  abcess  had  been  drained  and 
the  appendix  left  in. 

On  the  other  hand.  Dr.  Roswell  Park,  of  Buffalo, 
writes  that  he  hardly  ever  advises  a  secondary  operation 
to  remove  an  appendix  which  was  not  hunted  up  and 
removed  when  an  abcess  was  drained,  unless  it  seems  to 
be  producing  occasional  or  persistent,  even  though  mild, 
symptoms  or  discomfort,  i.  e.,  so  long  as  it  remains  inno- 
cent and  inoffensive,  he  does  not  feel  like  disturbing  it, 
but  when  it  growls,  he  would  urge  its  removal. 

I  have  also  written  to  twenty-three  patients  for  whom 
I  had  opened  and  drained  abcesses  without  making  an 
attempt  to  remove  the  appendix.  I  found  that  all  these 
cases  were  in  good  health,  that  none  of  them  had  been 
operated  on  a  second  time,  that  only  two  had  had  re- 
currence of  abdominal  symptoms,  and  therefore,  I  am 
disposed  to  agree  with  the  opinion  of  Dr.  Park,  that  a 
second  operation  should  not  be  done  as  a  routine  measure, 

117 


THE  MANAGEMENT  OF  APPENDICITIS 


but   only   when   called    for  by    symptoms    indicative   of 
trouble. 

III.  Appendicitis  with  Diffuse  Peritonitis. — Cases  in 
which  there  is  perforation  of  the  appendix  and  free  fluid 
in  the  general  peritoneal  cavity  have,  until  recently,  been 
the  terror  of  the  surgeon.  The  old  method  of  opening 
the  abdomen,  removing  the  appendix,  washing  out  the 
peritoneal  cavity,  and  making  counter  incisions  for  multi- 
ple drainage,  was  followed  by  a  mortality  of  about  eighty 
per  cent.  There  has  been,  to  my  mind,  no  recent  advance 
in  surgery  so  brilliant  in  theory  and  so  practical  in  results 
as  the  new  technique  of  treating  diffuse  suppurative  peri- 
tonitis. A  short  incision  is  made  over  the  appendix,  and 
the  diseased  organ  removed  if  it  is  readily  accessible.  A 
second  incision,  not  necessarily  more  than  an  inch  in 
length,  is  made  in  the  mid-line  over  the  pubes.  A  rubber 
tube  one-half  inch  in  diameter,  with  openings  on  the  side, 
is  introduced  through  the  supra-pubic  opening  and  car- 
ried to  the  bottom  of  the  pelvis.  No  irrigation  of  the 
abdomen  should  be  practiced,  no  effort  even  made  to 
sponge  out  the  pus,  but  a  voluminous  dressing  applied, 
and  the  patient  quickly  put  to  bed  in  an  exaggerated 
Fowler's  position.  Saline  solution  should  be  slowly  and 
continuously  given  by  rectum;  the  stomach  irrigated  if 
vomiting  is  persistent;  and  the  heart  and  kidneys  stimu- 
lated by  the  hypodermic  use  of  sulphate  of  spartine. 
Since  the  adoption  of  this  method  the  mortality  in  this 
class  of  cases  has  been  reduced  to  about  five  per  cent. 


ii8 


Appendicostomy  * 

The  operation  of  appendicostomy,  though  less  than 
four  years  old,  has  been  firmly  established  as  a  rational 
surgical  procedure.  It  consists  in  bringing  the  appendix 
through  an  abdominal  incision,  opening  its  tip  and  using 
its  lumen  through  which  to  irrigate  the  large  intestine. 
The  value  of  the  operation  will  be  appreciated  after  a 
consideration  of  the  following  facts: 

1.  Chronic  diseases  of  the  large  bowel  are  frequent. 

2.  They  are  exceedingly  rebellious  to  internal  or  local 
treatment,  as  drugs  by  mouth  are  rendered  inert  in  the 
small  intestines,  and  injections  by  rectum  are  not  only 
disagreeable,  but  often  inefficient  because  of  the  difficulty 
in  reaching  the  upper  portion  of  the  tract. 

3.  The  appendix  is  located  at  the  very  origin  of  the 
large  bowel ;  hence  fluids  introduced  through  it  reach 
every  part  of  the  canal. 

4.  The  operation  of  delivering,  attaching  and  opening 
the  appendix  is  so  simple  that  it  can  be  safely  done  by 
the  average  surgeon. 

5.  When  an  opening  is  once  formed  the  irrigation 
can  be  efficiently  carried  out  by  the  patient  without  pain 
or  discomfort. 

Experience  has  proved  that  the  mechanical  cleansing 
which  is  accomplished,  plus  the  therapeutic  effect  of  the 
antiseptic  or  astringent  solutions  employed,  usually  brings 


*  Read   at   the   meeting   of   the   Medical   Society   of   Virginia, 
October,  1906. 

119 


APPENDICOSTOMY 


quick  relief  to  patients  who  have  suffered  many  things 
of  many  doctors  without  benefit. 

Appendicostomy,  like  many  other  surgical  procedures, 
was  first  devised  extemporaneously  during  the  course  of 
another  operation.  In  1902,  Dr.  Robert  F.  Wier  opened 
an  abdomen  to  do  a  valvular  cecostomy  in  order  to  make 
a  fistula  through  which  he  could  irrigate  a  colon,  the 
seat  of  chronic  amebic  dysentery.  He  saw  the  appendix 
rise  prominently  into  the  wound  and  at  once  appreciated 
the  advantages  of  using  the  calibre  of  this  organ  for  his 
purpose.  He  stitched  the  tip  of  the  appendix  in  the  ab- 
dominal wound  and  closed  the  latter  around  it.  When 
about  to  apply  the  dressings,  the  thought  occurred  to 
him  that  the  appendix  might  not  be  patulous  and  he  there- 
fore amputated  its  tip  and  introduced  a  No.  12  soft  rub- 
ber catheter  through  its  lumen  into  the  cecum.  The 
latter  was  drawn  into  the  wound,  anchored  and  a  ligature 
thrown  around  the  stump  of  the  appendix  to  prevent 
leakage.  The  ligature  was  removed  in  twenty-four  hours 
and  two  days  later  irrigations  of  the  colon  were  begun. 
The  result  was  eminently  satisfactory. 

The  simplicity  of  the  operation,  its  freedom  from 
danger  and  the  ease  and  certainty  of  the  ultimate  closure 
of  the  fistula  appealed  at  once  to  the  profession,  and  ap- 
pendicostomy has  been  adopted  as  an  acceptable  sub- 
stitute for  cecostomy  in  all  but  a  few  selected  cases. 

The  original  technique  has  been  so  improved  upon  by 
various  surgeons,  chiefly  Meyer,  Dawbarn  and  Tuttle, 
that  now  a  most  acceptable  method  has  been  evolved. 

Indications. 

In  general,  the  operation  may  be  said  to  be  indicated  in 
all  cases  of  chronic,  non-malignant  diseases  of  the  colon, 

120 


APPENDICOSTOMY 


which  do  not  yield  to  medical  treatment.  It  has  been 
chiefly  employed  in  chronic  amebic  dysentery,  muco- 
membranous  colitis  and  syphilitic  and  tuberculous  ulcera- 
tions of  the  colon. 

Maunsell  has  employed  it  successfully  to  anchor  the 
cecum  in  a  case  of  volvulus,  and  in  another  to  prevent 
gaseous  distention  after  resection  of  the  small  intestine. 
He  also  recommends  it  as  a  means  of  relieving  tympanites 
due  to  intestinal  paresis  from  peritonitis. 

Keitley  has  employed  appendicostomy  as  a  substitute 
for  cecal  colostomy  in  a  case  of  carcinoma  of  the  tran- 
verse  colon ;  in  a  case  of  intussusception  of  the  ileum  into 
the  ascending  colon,  and  also  in  a  case  of  obstinate  consti- 
pation. He  recommends  it  to  facilitate  the  introduction 
of  food  when  feeding  by  way  of  the  bowel  is  necessary ; 
and  as  a  means  of  local  treatment  of  the  ulceration  of 
typhoid  as  suggested  by  Ewart. 

Sir  W.  H.  Bennett  suggests  the  possibilities  of  the 
operation  as,  first,  a  means  of  treating  diseases  of  the 
large  and  small  intestines ;  second,  a  means  of  relieving 
or  preventing  intestinal  distention ;  third,  a  means  of 
artificial  feeding;  fourth,  a  substitute  for  cecal  colostomy. 

Technique. 

The  patient  is  prepared  as  for  the  ''interval  operation" 
of  appendectomy.  The  abdomen  is  opened  by  the  grid- 
iron method  through  an  incision  large  enough  to  admit 
two  fingers.  The  appendix  is  grasped  and  brought  up 
into  the  wound,  the  artery  of  its  mesentery  tied  and  the 
organ  freed  to  its  base.  The  cecum  is  then  fastened  to 
the  parietal  peritoneum  at  the  lower  angle  of  the  wound 
by  sutures  on  either  side  and  above  the  appendix,  the 

121 


APPENDICOSTOMY 


last  suture  being  continued  to  close  the  peritoneum.  The 
lesser  appendiceal  artery  should  not  be  included  in  the 
side  sutures.  The  abdominal  incision  is  then  closed  in 
layers  by  sutures  of  catgut,  the  appendix  itself  being 
fastened  in  the  lower  angle  of  the  skin  wound  by  a  suture 
on  either  side.  The  protruding  appendix  is  then  wrapped 
with  thin  rubber  or  gutta  percha  tissue  and  the  dressings 
applied.  At  the  end  of  two  days,  the  dressings  are  re- 
moved. The  appendix  is  usually  found  gangrenous  at 
its  tip.  It  is  amputated  about  one-quarter  to  three-eighths 
of  an  inch  from  the  skin  and  its  lumen  carefully  dilated. 
A  catheter  should  then  be  introduced  and  secured  by  a 
ligature  tied  firmly  around  the  stump  of  the  appendix. 
The  ligature  serves  the  double  purpose  of  preventing 
leakage  around  the  catheter,  and  at  the  same  time  by 
constriction  cuts  off  the  stump  of  the  appendix  flush 
with  the  skin.  The  catheter  should  be  introduced  about 
two  to  four  inches.  If  there  is  abdominal  distention,  its 
lumen  should  be  left  open  to  allow  escape  of  flatus.  In 
the  absence  of  distention,  the  catheter  should  be  bent  on 
itself  and  fastened  with  a  safety  pin  to  prevent  leakage 
into  the  dressings.  On  the  third  or  fourth  day  irrigation 
may  be  begun. 

The  question  may  arise  whether  it  is  advisable  to  at- 
tempt appendicostomy  in  the  presence  of  a  small  atrophied 
appendix  even  though  it  be  patulous.  Will  its  calibre 
admit  a  catheter  large  enough  to  serve  the  purposes  of 
irrigation  ?  Tuttle  presents  two  cases  in  which  the  organ 
was  found  easily  dilatable  and  the  results  in  these  cases 
were  more  satisfactory  than  in  those  with  very  large 
appendices.  This  opinion  is  confirmed  by  C.  B.  Kietley, 
who,  in  a  case  of  carcinoma  of  the  transverse  colon  with 

122 


APPENDICOSTOMY 


slender  atrophied  appendix,  was  able  to  dilate  the  latter 
until  he  could  introduce  a  small  sized  rectal  tube,  the 
opening  afterwards  serving  as  an  artificial  anus.  In  my 
own  case  herewith  reported,  no  difficulty  was  encountered 
in  dilating  an  appendix  greatly  atrophied  and  adherent 
as  a  result  of  previous  inflammation. 

Time  for  Opening  the  Appendix 
If  there  is  any  doubt  of  the  patency  of  the  appendix 
it  should  be  opened  before  the  bowel  is  fixed  to  the  parie- 
tal peritoneum  in  order  that  if  its  canal  is  obliterated 
the  operator  may  abandon  appendicostomy  and  proceed 
at  once  to  a  cecostomy.  The  surgeon,  by  rolling  the  ap- 
pendix between  his  fingers,  can  usually  determine  whether 
the  organ  is  patulous.  If  it  is  permeable,  he  should  not 
take  the  risk  of  infecting  the  wound  by  opening  the  canal 
until  two  or  three  days  after  the  operation.  This  is 
strongly  insisted  upon  by  Tuttle.  Every  case  of  post- 
operative hernia  noted  by  this  observer  has  followed  the 
cases  in  which  the  appendix  was  opened  at  the  time  of 
operation,  and  in  all  cases  there  has  been  subsequent  if 
not  consequent  infection.  Of  course  such  a  practice  is 
not  advisable  in  cases  in  which  the  operation  is  done  for 
intestinal  obstruction  or  paralysis,  for  artificial  feeding, 
or  any  very  acute  conditions.  In  such  cases,  just  as  in 
colostomy,  a  few  hours  delay  is  all  that  is  necessary. 
When  opened  early  the  appendix  should  be  cut  oflf  fully 
half  an  inch  from  the  skin,  a  catheter  introduced  and  a 
thread  tied  around  the  stump  to  avoid  leakage. 

Solutions  for  Irrigation. 
The  selection  of  a  fluid  for  irrigation  will  depend  upon 
the  diseased  condition.    In  amebic  dysentery  the  consen- 

123 


APPENDICOSTOMY 


sus  of  opinion  is  largely  in  favor  of  quinine  solutions. 
Tuttle  recommends  normal  saline  solution  at  a  tempera- 
ture of  65  to  75  degrees  F.,  and  advises  that  care  be 
exercised  to  use  normal  salt  solution  and  not  brine. 

In  catarrhal  colitis,  with  or  without  ulcerations,  solu- 
tions of  nitrate  of  silver  1-5000,  argyrol  5  per  cent,  to 
25  per  cent.,  peroxide  of  hydrogen  10  per  cent,  to  20  per 
cent.,  and  aqueous  fluid  extract  of  krameria  10  per  cent., 
have  all  been  used  with  more  or  less  satisfaction.  Some 
of  these  cases  yield  very  promptly  and  others  are  very 
obstinate.  Ewart  reports  a  case  in  which  appendicostomy 
was  performed  for  colitis  with  diarrhea  and  profuse 
bloody  discharges.  The  hemorrhages  continued  in  spite 
of  all  the  ordinary  irrigations,  but  finally  ceased  after 
injecting  liquid  paraffin  into  the  colon. 

When  and  How  to  Close  the  Opening. 

The  time  at  which  the  appendiscostomy  fistula  should 
be  closed  depends  upon  the  disease  for  which  the  opera- 
tion has  been  performed,  the  history,  condition  and  symp- 
toms presented  by  the  patient,  and  the  amount  of  annoy- 
ance the  fistula  gives. 

In  cases  of  amebic  dysentery  there  is  usually  an  ap- 
parent cure  in  four  weeks  or  less.  It  would  not  be  wise, 
however,  to  close  the  opening  at  this  time  as  periods 
of  quiescence  lasting  some  times  months  occur  in  the 
disease  even  without  treatment.  These  patients  should 
be  advised  to  wait  six  or  nine  months,  and  if  they  are 
to  return  to  tropical  regions  the  opening  should  be  kept 
open  permanently  to  facilitate  prompt  and  effectual 
treatment  in  case  of  reinfection. 

In  cases  of  simple  mucous  colitis,  the  opening  may  be 

124 


APPENDICOSTOMY 


closed  after  mucous  has  been  absent  from  the  stools  for 
several  weeks  and  the  bowel  movements  have  become 
regular  without  irrigation  or  laxatives. 

In  cases  of  the  various  forms  of  ulcerative  colitis  too 
much  stress  cannot  be  laid  on  the  advisability  of  keeping 
the  fistual  open  for  a  considerable  length  of  time.  The 
only  disappointments  from  the  operation,  so  far  as  known, 
have  followed  too  early  closure.  It  is  important  in  these 
cases  to  aid  the  colonic  flushings  by  proper  internal  medi- 
cation and  judiciously  selected  articles  of  diet. 

In  cases  where  the  operation  has  been  performed  for 
the  relief  of  tuberculous  ulceration,  the  fistula  should  be 
kept  open  permanently.  When  made  for  the  relief  of 
intestinal  distention,  caused  by  peritonitis  or  volvulus, 
the  fistula  may  be  closed  as  soon  as  the  primary  condi- 
tion has  disappeared.  In  other  conditions  the  time  of 
closure  must  be  left  to  the  judgment  of  the  operator,  as 
there  are  no  statistics  upon  which  to  base  conclusions. 
To  close  the  fistula  is  usually  simple  and  easy.  The  appli- 
cation of  nitric  acid  or  the  actual  cautery  to  the  mucous 
lining  has  invariably  and  promptly  been  followed  by 
closure  of  the  aperture.  If,  however,  it  is  deemed  advis- 
able, the  stump  of  the  appendix  may  be  dissected  out  and 
the  small  abdominal  wound  sutured. 

Results. 
In  forty-four  cases  of  dysentery  there  were  six  deaths, 
but  none  of  them  due  to  the  operation.  Two  were  from 
unsuspected  tuberculosis,  two  from  extreme  ulceration 
of  the  bowel  with  chronic  nephritis,  one  from  exhaustion 
before  the  appendix  was  opened,  and  one  from  cerebral 

125 


APPENDICOSTOAIY 


disease  three  months  after  the  operation.  The  remainder 
of  the  cases  (38)  are  reported  cured. 

In  sixteen  cases  of  mucous  colitis  the  reports  are  all 
favorable.  In  some  of  them,  however,  it  is  difficult  to 
tell  how  much  good  was  due  to  the  removal  of  the  appen- 
dix and  how  much  to  the  effect  of  appendicostomy.  The 
relationship  between  chronic  appendicitis,  with  adhesions, 
and  chronic  muco-membranous  colitis  is  very  close,  and 
the  etiologic  influence  of  the  one  on  the  other  merits  a 
wider  discussion  than  is  permitted  by  the  limits  of  this 
paper.  Suffice  it  to  say  that  by  appendicostomy  we  get 
rid  of  the  appendix,  whether  it  be  the  cause  or  effect  of 
colitis,  and  at  the  same  time  give  access  to  the  parts  for 
local  treatment. 

In  the  cases  reported,  where  the  operation  was  done 
for  syphilitic  ulceration,  the  patients  appear  to  have  been 
greatly  benefitted  if  not  permanently  cured.  In  the  cases 
of  papilloma  and  carcinoma,  the  operation  was  performed 
only  as  a  palliative  measure.  In  the  cases  of  volvulus 
and  intussusception  the  operation  was  effectual. 

REPORT    OF   AUTHOR'S    CASE. 

Mrs.  X.,  aged  46,  patient  of  Dr.  W.  S.  Gordon,  of  Richmond, 
Va.,  admitted  to  St.  Luke's  Hospital  June  14,  1906.  History  of 
typical  attack  of  appendicitis  about  puberty.  For  thirty  years 
had  suffered  with  occasional  pain  in  right  iliac  region.  Two 
years  ago  had  an  attack  of  colitis.  Recovered  and  remained 
well  for  twelve  months  and  then  had  recurrence.  Disease  grew 
worse  despite  persistent  and  intelligent  treatment.  Was  placed 
at  one  of  the  hospitals  of  this  city  where  diet,  rest,  astringent 
and  rectal  irrigations  were  tried  for  some  weeks  without  per- 
manent benefit.  During  past  six  months  had  suffered  constant 
aodominal  pain,  attended  by  profuse  diarrhea,  with  loss  of 
thirty-five  pounds  in  weight. 

126 


APPENDICOSTOMY 


Operation  of  appendicostomy  performed  June  20,  1906.  Appen- 
dix was  found  atrophied  and  adherent,  but  was  Hberated  and 
brought  through  the  abdominal  wound  by  the  technique  previ- 
ously described.  Two  or  three  days  later  the  appendix  was 
amputated,  its  calibre  dilated,  a  catheter  inserted  and  irriga- 
tion of  the  colon  begun.  The  patient  was  out  of  bed  on  the 
fifteenth  day  and  was  discharged  on  the  22d  day  after  operation. 

As  long  as  the  patient  was  in  the  hospital  she  did  admirably, 
but  shortly  after  her  return  home  she  had  a  sharp  recurrence 
of  her  old  symptoms.  This  was  partly  due  to  the  nature  of  her 
disease,  but  largely  accentuated  by  too  heroic  treatment.  She 
was  a  physician  and  the  wife  of  a  physician,  and  as  I  was  in 
Europe,  they  were  left  to  their  own  resources,  and,  as  is  usual 
in  such  cases,  owing  to  over-anxiety,  they  tried  too  many  reme- 
dies. Finally,  after  correspondence  with  Dr.  Tuttle,  the  patient 
was  put  on  sulpho-carbolate  of  zinc  and  oil  of  turpentine,  and 
the  colon  irrigated  with  a  teaspoonful  of  salt  and  a  teaspoonful 
of  bicarbonate  of  soda  to  a  quart  of  hot  water  (120°  F.)  for 
three  days,  followed  by  ly^  per  cent,  solution  of  ichthyol  on 
the  fourth  day.  This  resulted  in  controlling  the  diarrhea  and  a 
gradual  return  to  normal  fecal  movements.  The  appendicostomy 
fistula  was  kept  open  for  three  weeks  after  the  mucous  dis- 
appeared and  then  allowed  to  close.  The  patient  has  gained 
more  than  fifteen  pounds  in  weight  and  believes  herself  cured. 


127 


Pylorospasm  * 

Twenty  years  ago  the  physician  held  undisputed  sway 
in  the  treatment  of  digestive  disturbances,  and  the  sug- 
gestion that  dyspepsia  could  be  cured  by  surgery,  when 
medicinal,  dietetic  and  hygienic  measures  had  failed, 
would  have  been  regarded  as  an  absurdity. 

Ten  years  ago  the  surgeon  took  possession  of  the  field, 
and  for  a  time  the  operation  of  gastro-enterostomy  was 
considered  a  panacea  for  all  gastric  disorders.  It  was 
found,  however,  that  while  the  operation  in  some  cases 
accomplished  brilliant  cures,  in  others  it  not  only  did  not 
relieve,  but  actually  increased,  the  patient's  distress. 

Today  it  has  been  demonstrated  that  chronic  and  re- 
curring indigestion  is  rarely,  if  ever,  due  to  functional 
causes,  and  cannot  be  cured  by  efforts  to  correct  errors  of 
secretion.  It  is  almost  invariably  caused  by  organic  dis- 
ease of  the  stomach  or  other  organs,  and  can  be  corrected 
only  by  operative  intervention.  In  nine  cases  out  of  ten, 
while  the  symptoms  are  gastric,  the  cause  is  appendicitis, 
cholecystitis,  pancreatitis,  or  duodenal  ulcer:  and  while 
the  treatment  is  surgical,  the  operation  is  not  done  on  the 
stomach.  A  gastro-enterostomy  will  cure  the  symptoms 
due  to  an  organic  obstruction  of  the  pylorus  such  as  re- 
sult from  cicatricial  contraction  of  an  ulcer,  because  it 
relieves  the  condition  by  affording  a  new  exit  for  the 
stomach  contents.    The  operation  w^ill  not  cure,  but  will 


*  Read  at  meeting  of  the  Southern  Surgical  and  Gynecological 
Association,  Nashville,  Tenn.,  December,  1910. 

129 


PYLOROSPASM 


aggravate,  the  symptoms  due  to  a  spasmodic  obstruction 
of  the  pylorus  such  as  results  reflexly  from  nervous  stim- 
ulation, because  it  overcomes  t\ie  effort  being  made  by 
nature  to  prevent  the  invasion  of  the  intestines  by  irri- 
tating stomach  contents.  Obstruction  of  the  pylorus  may 
be  organic  or  spasmodic.  The  first  is  mechanical  and 
should  be  relieved  by  making  a  new  exit  for  the  stomach 
contents ;  the  second  is  nervous  and  should  be  relieved 
by  diagnosticating  and  correcting  the  cause  which  pro- 
duces it. 

Spasm  of  the  pylorus,  or  pylorospasm  as  it  is  generally 
called,  is  a  very  common  trouble.  It  is  not  a  disease,  but 
a  symptom.  It  may  be  caused  by  rapid  eating,  by  indi- 
gestible food,  by  an  ulcer  or  other  lesion  of  the  stomach, 
but  it  is  most  frequently  the  expression  of  disease  of  some 
remote  abdominal  structure.  Plow  appendicitis  or  cho- 
lecystitis causes  gastric  symptoms  has  never  been  satis- 
factorily explained.  It  is  believed  that  irritation  trans- 
mitted to  the  stomach  through  the  sympathetic  nervous 
system  causes  an  excessive  secretion  of  hydrochloric  acid. 
The  resulting  hyperchlorhydria  causes  spasm  of  the 
pylorus ;  the  pylorospasm  causes  retention  of  food  beyond 
the  physiologic  limit,  and  finally  there  comes  motor  in- 
sufficiency, food  stagnation  and  dilation  of  the  stomach. 

The  most  prominent  symptom  of  pylorospasm  is  a 
cramping  pain  in  the  epigastrium,  which  may  last  only  a 
few  minutes  or  may  continue  for  several  hours.  In  some 
cases  the  spasm  may  relax  suddenly;  in  others  it  may 
terminate  slowly  and  gradually.  Some  patients  have  at- 
tacks several  times  a  day ;  others  at  intervals  of  weeks ; 
and  others  still  only  once  or  twice  a  year.  In  the  in- 
terval  between   attacks,   the   digestion   may   be   normal. 

130 


PYLOROSPASM 


During  attacks  peristalsis  of  the  stomach  is  increased,  but 
food  cannot  pass  through  the  pylorus,  and  often  relief 
comes  only  after  vomiting.  The  patient  usually  diets 
strictly,  and  loses  flesh  and  strength  steadily  from  star- 
vation and  autointoxication. 

During  the  last  few  years  I  have  recognized,  treated 
and  cured  a  progressively  increasing  number  of  cases  of 
pylorospasm.  In  no  other  class  of  patients,  with  possibly 
the  exception  of  epileptics,  is  it  necessary  to  be  so 
thorough  in  preliminary  examination  and  so  patient  in 
post-operative  treatment.  The  real  cause  of  the  condition 
must  be  found,  and  after  it  has  been  removed  the  patient 
must  be  systematically  treated  until  the  hypersensitiveness 
of  the  pyloric  muscle  is  relieved,  and  its  spasm  habit  is 
overcome.  This  will  be  well  illustrated  by  one  of  my 
first  cases. 

Miss  E.,  aged  32,  a  thin,  anemic  and  nervous  patient,  gave  a 
history  of  chronic  dyspepsia  attended  by  frequent  attacks  of 
violent  pain  in  the  upper  abdomen.  A  diagnosis  of  gall-stones 
was  made  and  an  operation  advised.  The  abdomen  was  opened, 
the  gall-bladder  exposed,  and  it  was  found  to  contain  several 
large  gall-stones.  They  were  removed,  a  drain  was  inserted, 
and  the  incision  was  closed.  No  examination  was  made  of  other 
abdominal  organs.  A  week  after  the  operation  the  patient  had 
a  return  of  her  old  pain,  and  the  paroxysms  became  so  frequent 
and  distressing  that  her  familj^  was  told  that  it  was  probable 
that  a  stone  had  been  overlooked  and  it  was  advisable  to  re- 
open the  abdomen  and  try  to  remove  it.  At  the  second  opera- 
tion the  gall-bladder  and  ducts  were  carefully  palpated,  with 
negative  results.  The  stomach  was  then  delivered  and  ex- 
amined. The  pylorus  was  found  hard  and  rigid,  with  a  lumen 
which  would  not  admit  the  tip  of  the  finger.  While  handling 
it  in  search  of  evidences  of  ulceration,  the  spasm  suddenly  gave 
way,  the  tissues  became  soft  and  elastic,  and  a  finger  could 
readily  be  invaginated  through  the  opening.     Then,  for  the  first 

131 


PYLOROSPASM 


time,  the  nature  of  the  case  was  comprehended.  The  stomach 
was  normal;  the  gall-stones  were  an  innocent  coincidence;  the 
cause  of  the  pylorospasm  must  be  found  elsewhere.  The  ap- 
pendix, which,  until  then,  had  not  been  suspected  of  disease, 
was  brought  into  view.  It  was  inflamed  and  contained  several 
enteroliths,  and  was  removed.  The  patient  recovered  from  the 
operation,  but  for  some  months  had  recurrence  of  pain  after 
any  imprudence  in  eating.  She  was  carefully  and  intelligently 
treated  by  her  family  physician  and  is  now  completely  well. 

This  paper  is  intended  only  to  be  suggestive.  Its  pur- 
poses are  to  impress : 

First. — The  necessity  of  differentiating  between  gastric 
symptoms  due  to  organic  disease  of  the  stomach  and  those 
reflex  from  other  organs. 

Second. — The  impropriety  of  performing  a  gastroenter- 
ostomy for  spasm  of  the  pylorus. 

Third. — The  advisability,  at  the  time  of  operation,  of 
examining  all  abdominal  organs  and  correcting  every  ab- 
normality, lest  the  obvious  may  not  be  the  real  cause  of 
the  symptoms. 

Fourth. — The  importance  of  the  post-operative  and 
post-hospital  treatment  of  patients  to  overcome  the  spasm 
habit  of  the  pyloric  sphincter. 


132 


Etiology   and   Symptomatology   of 
Gall  Stones  * 

The  liver  is  the  largest  and  one  of  the  most  important 
organs  of  the  abdomen.  Its  most  obvious  function  is  the 
production  of  bile.  One  of  its  most  essential  duties,  how- 
ever, is  the  destruction  of  the  bacteria  coming  to  it  from 
the  digestive  tract  through  the  portal  system  before  the 
blood  enters  the  systemic  circulation  by  way  of  the  hepatic 
vein.  The  liver  secretes  between  20  and  30  ounces  of  bile 
every  24  hours.  Healthy  bile  was  at  one  time  supposed 
to  be  free  from  germ  life  and  even  to  have  mild  apti- 
septic  properties :  more  recent  and  accurate  investigations, 
however,  show  that  it  always  contains  a  moderate  num- 
ber of  bacteria  and  that  it  is  a  good  culture  medium. 

Most  of  the  bile  produced  by  the  liver  passes  directly 
to  the  duodenum  through  the  hepatic  and  common  ducts. 
A  small  proportion  passes  up  the  cystic  duct  to  the  gall- 
bladder where  it  is  stored  and  somewhat  modified  by  ab- 
sorption and  admixture  with  mucous.  When  stimulated 
the  gall-bladder  contracts  and  forces  its  contents  back 
through  the  cystic  duct  to  the  general  bile  stream.  Bile, 
on  reaching  the  intestinal  tract,  stimulates  pancreatic 
secretion,  neutralizes  the  acid  chyme  of  the  stomach, 
emulsifies  fat  present  in  food,  and  excites  the  peristaltic 
action  of  the  bowel.  When  bile  reaches  the  cecum  the 
fluid  element  is  absorbed  and  returned  to  the  circulation 


*  Part  of  a  Clinical  Lecture  delivered  at  the  University  College 
of  Medicine,  Richmond,  Va.,  November,  1912. 

133 


ETIOLOGY  AND  SYMPTOMATOLOGY  OF 

while  the  pigments  and  waste  products  are  excreted  in  the 
feces. 

The  Gall-Bladder  is  a  pear-shaped  organ  capable  of 
holding  about  one  ounce  af  bile.  Its  function  is  unknown 
and  people  seem  to  get  along  as  well  without  it  as  they 
do  with  it.  The  amount  of  bile  it  is  capable  of  holding 
is  so  small,  compared  with  the  total  secretion  of  the  liver, 
that  it  cannot  act  in  an  important  way  as  a  reservoir. 
Some  think  it  acts  as  the  air  chamber  to  a  fire  engine, 
regulating  the  flow  of  the  stream,  others  that  it  secretes 
mucous,  which  mixed  with  bile  serves  as  a  lubricant  to 
the  ducts.  At  any  rate  the  gall-gladder,  like  the  appen- 
dix, is  a  non-essential  structure. 

The  Hepatic  Duct  begins  at  the  transverse  fissure  of 
the  liver.  It  is  about  two  inches  in  length  and  one-sixth 
of  an  inch  in  diameter.  It  unites  with  the  cystic  duct  to 
form  the  common  duct. 

The  Cystic  Duct  is  about  13^^  inches  long  and  ^  inch 
in  diameter.  Its  mucous  lining  is  thrown  in  crescentic 
folds  which  normally  prevent  the  passage  of  a  probe 
from  the  gall  bladder  to  the  common  duct. 

The  Common  Duct  is  about  three  inches  long.  It  emp- 
ties into  the  duodenum  together  with  the  pancreatic  duct 
at  the  ampulla  of  Vater.  The  common  duct  is  divided  for 
description  into  three  portions.  The  supra-duodenal,  the 
retro-duodenal  and  the  trans-duodenal.  The  supra-duod- 
enal is  about  13/2  inches  long.  It  runs  downward  in  the 
free  edge  of  the  gastrohepatic  omentum  and  forms  the 
anterior  boundary  of  the  foramen  of  Winslow.  The 
retro-duodenal  portion  of  the  duct  is  about  one  inch  long 
and,  as  its  name  implies,  lies  behind  the  duodenum.  In 
40%  of  cases  it  runs  in  a  grove  on  the  head  of  the  pan- 

134 


GALL  STONES 


creas.  In  60%  of  cases  it  passes  directly  through  the 
pancreatic  tissue.  The  trans-duodenal  portion  of  the  duct 
is  about  Y2.  inch  long  and  passes  obliquely  through  the 
wall  of  the  gut  to  open  in  common  with  the  pancreatic 
duct  at  the  ampulla  of  Vater.  The  first  portion  of  the 
common  duct  is  easily  accessible  to  palpation  and  manipu- 
lation as  it  can  be  raised  by  hooking  the  fingers  in  the 
foramen  of  Winslow.  The  second  and  third  portions 
of  the  common  duct  are  difficult  of  access  and  it  is  often 
necessary  to  make  an  incision  into  the  duodenum  to  ap- 
proach them  surgically. 

The  Pancreas  is  formed  in  the  embryo  by  two  buds. 
It  retains  to  a  certain  extent  its  primitive  form  and  has 
two  lobes  which  are  drained  by  two  ducts  having  separate 
openings  into  the  duodenum.  The  duct  of  Wirsung  is  the 
main  drain  of  the  pancreas  in  83%  of  individuals.  It 
opens  into  the  duodenum  at  the  ampulla  of  Vater  together 
with  the  common  duct.  This  has  been  termed  an  unfor- 
tunate association  of  terminal  facilities  between  the  liver 
and  pancreas,  as  interference  with  traffic  in  one  system 
may  block  the  service  in  the  other.  The  duct  of  Santorini 
is  the  main  drain  of  the  pancreas  in  12%  of  indi- 
viduals. When  the  other  duct  is  obstructed  it  is  capable 
of  acting  as  the  main  drain  in'  54%  of  the  cases.  It  may 
open  into  the  duodenum  a  short  distance  below  the  pylo- 
rus. 

Gail-Stones  are  concretions  formed  in  the  gall-bladder. 
It  is  possible  they  may  form  in  the  hepatic  or  common 
duct  but  such  cases  are  extremely  rare.  Gall-stones  are 
not  calcareous  but  fatty  substances,  as  can  be  demon- 
strated by  subjecting  one  to  the  heat  of  an  open  flame 
when  it  will  soften  and  burn  much  like  sealing  wax. 
Gallstones  are  composed  of  cholesterine,  bile  pigments 

135 


ETIOLOGY  AND  SYMPTOMATOLOGY  OF 

and  lime  salts.  The  proportion  of  these  elements  are 
not  constant  and  as  a  result  the  color  of  the  stone  may 
vary  from  light  yellow  to  dark  green  or  black. 

Gall  stones  vary  in  size  and  number;  they  may  be  as 
small  as  mustard  seeds  or  as  large  as  goose  eggs.  If 
multiple  they  are  often  faceted  from  pressure  one  against 
another.  Numererous  cases  have  been  reported  where 
several  thousands  have  been  found  in  one  patient. 

Gall-stones  are  formed  in  from  a  few  days  to  a  few 
weeks.  They  are  usually  all  formed  at  the  same  time  and 
are  symmetrical  although  cases  are  sometimes  seen  where 
there  are  several  crops  of  stones  as  shown  by  the  entirely 
different  color,  size,  shape  and  proportion  of  chemical 
constituents. 

Gall-stones  frequently  migrate  from  the  gall-bladder. 
They  often  pass  in  the  cystic,  hepatic  and  common  ducts. 
They  frequently  reach  the  duodenum  either  by  way  of  the 
ducts  or  through  a  fistulous  opening  between  the  gall- 
bladder and  bowel.  They  are  sometimes  vomited  and 
often  pass  at  stool.  Occassionally  they  enter  the  appen- 
dix and  sometimes  they  lodge  at  the  iliocecal  valve  or 
some  other  portion  of  the  intestinal  canal  producing  ob- 
struction. 

The  cause  of  the  gall-stone  formation  has  been  a  ques- 
tion giving  rise  to  much  discussion.  It  is  a  fact  that 
50%  of  gall  stones  occur  in  patients  over  40  years  of  age ; 
that  75%  of  all  gall  stones  occur  in  women  and  that 
90%  of  these  women  have  borne  children.  It  is  also  a 
fact  that  33%  of  people  with  gall-stones  give  history  of 
typhoid  fever  and  25%  give  history  of  having  had  an 
attack  of  appendicitis.  Finally,  it  is  a  fact  that  gall- 
stones are  more  common  in  people  who  lead  sedentary 

136 


GALL  STONES 


lives,  eat  and  drink  imprudently  and  suffer  from  consti- 
pation and  obesity. 

The  theory  of  the  etiology  of  gall  stone  disease  at 
present  accepted  is  that  the  condition  is  due  to  the  com- 
bination of  predisposing  and  essential  causes.  The  predis- 
posing causes  are  supposed  to  be  factors  which  produce 
stagnation  of  the  biliary  current,  under  which  must  be 
considered  age,  sex,  pregnancy,  tight  lacing,  obesity,  con- 
stipation, imprudence  in  eating  and  drinking,  lack  of  exer- 
cise and  fresh  air  and  other  errors  in  the  habits  of  living. 

The  essential  cause  is  supposed  to  be  the  infection  of 
the  gall-bladder  and  the  production  of  chronic  cholecysti- 
tis. The  microorganisms  most  often  responsible  for  the 
infection  are  of  the  colon  group,  including  the  typhoid 
bacillus.  Welsh  has  found  the  typhoid  germ  in  the  gall- 
bladder seven  years  after  an  attack  of  typhoid  fever,  and 
clumps  of  bacteria  are  frequently  found  in  the  nucleus 
of  gall-stones.  Attempts  to  produce  gall-stones  artifi- 
cially in  animals  by  infection  have  usually  failed  because 
the  resulting  inflammation  has  been  so  acute  as  to  pro- 
duce destruction  of  the  mucous  lining  of  the  gall-bladder. 
Success  has  only  been  secured  when  the  germs  em- 
ployed were  so  attenuated  as  simply  to  produce  irritation. 

The  avenue  by  which  the  bacteria  reach  the  gall-blad- 
der is  a  matter  of  dispute.  Some  authorities  claim  that 
they  pass  directly  from  the  intestinal  tract  through  the 
common  duct.  This  theory  is  favored  by  the  observation 
of  Bond  that  particles  of  indigo  carmin  placed  in  the 
rectum  were  carried  up  by  a  reverse  mucous  current  and 
could  be  demonstrated  after  a  certain  time  in  the  gall- 
bladder; also  by  the  observation  that  the  bacillus  prodi- 
giosus  introduced  within  the  anus  could  be  recovered  in 

137 


ETIOLOGY  AND  SYMPTOMATOLOGY  OF 

two  hours  from  the  animal's  mouth.  Opposed  to  this 
theory  are  the  facts  that  the  duodenum  is  usually  sterile 
and  that  infection  would  travel  with  difficulty  up  the 
common  duct  in  opposition  to  the  rapidly  flowing  stream 
of  bile. 

Other  authorities  claim  that  the  infection  reaches  the 
liver  through  the  portal  blood  and  is  conveyed  to  the  gall- 
bladder by  the  agency  of  the  bile.  In  ordinary  health  the 
blood  going  to  the  liver  through  the  portal  system  con- 
tains many  bacteria  picked  up  in  the  passage  through 
the  digestive  tract.  The  reason  for  its  going  through 
the  liver  prior  to  return  to  the  general  circulation 
is  to  permit  the  annihilation  or  attenuation  of  its  in- 
fection. If  this  infection  be  present  in  health  it  exists  to 
a  much  greater  extent  in  disease.  Proctitis,  colitis,  enter- 
itis, appendicitis,  typhoid  fever,  ulcer  of  the  duodenum  or 
stomach,  abcess  of  the  spleen,  inflammation  of  the  pan- 
creas or  lesion  of  the  liver  itself,  would  all  throw  an 
additional  amount  of  infection  in  the  blood  stream.  As 
a  result  the  bile  would  be  infectious  and  chronic  cholecy- 
stitis with  gall-stone  result.  This  theory  explains  the 
frequency  with  which  gall-stones  follow  appendicitis, 
typhoid  fever,  duodenal  ulcer  and  other  diseases  of  the 
gastro-intestinal  tract. 

Post-mortem  examinations  made  by  pathologists  of  all 
patients  dying  in  large  hospitals  and  the  examination  of 
the  upper  abdomen  by  surgeons  as  a  routine  measure  in 
abdominal  sections  have  shown  the  presence  of  gall-stones 
in  many  cases  where  they  were  not  suspected  to  exist.  It 
is  stated  by  several  reliable  authorities  that  about  one  per- 
son in  ten  has  gall-stones.  If  this  be  true,  the  condition 
should  be  constantly  borne  in  mind  when  examining  a 

138 


GALL  STONES 


patient  with  abdominal  trouble,  and  both  physician  and 
surgeon  should  make  a  thorough  study  of  the  sympto- 
matology of  the  disease  in  order  that  he  may  recognize  it 
early  and  treat  it  properly. 

Indigestion  is  the  earliest  and  most  frequent  symptom 
of  gall-stones.  It  is  not  produced  by  imprudence  in  eat- 
ing, comes  on  without  definite  relation  to  taking  food,  and 
is  usually  relieved  by  vomiting. 

Pain  located  in  the  epigastrium  and  radiating  to  the 
back  is  another  fairly  constant  symptom.  It  is  dull  aching 
in  character  and  varies  in  intensity.  It  is  increased  when 
the  gall-bladder  is  distended  and  relieved  when  it  is 
emptied. 

Tenderness  over  the  gall-bladder  can  generally  be  eli- 
cited by  spreading  the  fingers  of  the  left  hand  over  the 
patient's  ribs  and  hooking  the  thumb  under  the  costal 
margin.  When  the  patient  takes  a  deep  inspiration,  the 
diaphragm  forces  the  liver  down  and  the  sensitive  gall- 
bladder coming  in  contact  with  the  examiner's  finger 
causes  a  sudden  catch  in  the  patient's  breath. 

Colic  is  a  familiar  symptom.  It  is  due  to  the  sudden 
blodkage  of  the  duct  and  the  muscular  contraction  of  the 
gall-bladder  to  overcome  the  obstruction.  Colic  is  abrupt 
in  its  onset  and  sudden  in  its  relief.  The  patient  is 
doubled  up  in  agony,  and  there  is  faintness,  nausea  and 
vomiting. 

Jaundice  is  not  a  very  frequent  symptom  of  gall-stones. 
According  to  Murphy  it  only  occurs  in  one  out  of  seven 
cases.  Jaundice  is  due  to  obstruction  of  the  common 
duct.  Bile,  unable  to  escape  into  the  duodenum,  exerts  a 
back  pressure  on  the  liver  and  there  is  rupture  of  the 
biliary  radicles.     Bile  is  taken  up  by  the  lymphatics  and 

130 


ETIOLOGY  AND  SYMPTOMATOLOGY  OF 

carried  to  the  general  circulation  causing  the  characteris- 
tic discoloration  of  the  eyes  and  skin,  and  giving,  sooner 
or  later,  the  symptoms  of  cholemia. 

Obstruction  of  the  common  duct  may  be  caused  by  it 
being  plugged  by  a  stone  from  within  or  compressed  by 
a  growth  from  without.  Attention  has  been  called  to  the 
fact  that  the  retro-duodenal  portion  of  the  common  duct 
lies  in  or  on  the  head  of  the  pancreas.  Disease  of  the 
pancreas,  whether  inflammatory  or  malignant,  which 
causes  it  to  be  enlarged,  will  by  pressure  obstruct  the 
common  duct  and  produce  jaundice.  It  is  a  fact  which 
cannot  be  too  strongly  impressed  that  most  cases  of  gall- 
stones are  not  attended  by  jaundice  and  most  cases  of 
jaundice  are  not  due  to  gall-stones.  The  differentiation 
of  jaundice  due  to  gall-stones  and  jaundice  due  to  malig- 
nant disease  is  based  on  the  fact  that  jaundice  due  to  gall- 
stones is  usually  preceded  by  colicky  pain,  while  jaundice 
due  to  cancer  is  not  attended  by  pain.  Also  by  the  fact 
that  jaundice  due  to  gall-stones  varies  in  intensity,  deep- 
ening after  an  attack  of  pain  and  then  clearing  up,  while 
jaundice  due  to  malignant  disease  gradually  gets  deeper 
and  deeper  and  never  lessens.  There  is  yet  another  fact, 
first  emphasized  by  Courvoisier  namely,  that  in  jaundice 
due  to  a  stone  in  the  common  duct  the  gall-bladder  is  con- 
tracted and  cannot  be  palpated,  while  in  jaundice  due  to 
malignant  disease  the  gall-bladder  is  distended  and  can 
usually  be  felt. 

Fever  is  a  frequent  symptom  of  gall-stone  disease,  due 
to  an  increase  in  the  acuteness  of  infection.  It  is  marked 
by  its  rapid  rise  and  abrupt  termination.  If  the  range  of 
the  temperature  be  charted,  it  gives  an  appearance  which 

140 


GALL  STONES 


Moynihan  calls  "The  Steeple  Chart"  and  Murphy  terms 
"The  Temperature  Angle  of  Cholangic  Infection." 
Tumor  of  a  movable  pear-shaped  mass  which  can  be 
palpated  in  the  region  of  the  gall-bladder  indicates  either 
obstruction  of  the  cystic  duct  with  a  stone  and  distention 
of  the  viscus  with  mucous,  or  the  obstruction  of  the  com- 
mon duct  by  cancer  and  the  distention  of  the  organ  with 
bile. 

It  sounds  like  a  paradox,  but  it  is  a  deplorable  fact 
that  most  cases  of  gall-stones  are  treated  by  the  physi- 
cian for  indigestion,  and  that  many  cases  of  supposed  gall- 
stones operated  on  by  surgeons  are  the  victims  of  some 
other  disease.  Mistakes  in  the  diagnosis  of  gall-stones 
are  due  to  all  the  early  symptoms  being  referred  to  the 
stomach  and  the  supposedly  pathognomic  symptom  of 
jaundice  being  most  frequently  due  to  cancer. 


141 


Diagnosis   and  Treatment  of 
Gall  Stones* 

Cases  of  gall-stones  have  been  recognized  and  treatec 
for  many  centuries,  but  until  Marion  Sims  did  the  first 
premeditiated  operation  for  the  removal  of  a  biliary  con- 
cretion, some  twenty-six  years  ago,  the  disease  was  con- 
sidered a  medical  one  and  not  amenable  to  surgery.  The 
belief  that  gall-stones  could  be  relieved  bv  diet,  exercise, 
mineral  waters  and  drugs  has  been  so  long  entertained 
that  the  laity  and  many  of  the  profession  still  think  that 
surgery  should  be  resorted  to  only  when  continued  jaun- 
dice or  profound  sepsis  threaten  the  life  of  the  patient. 
This  fallacy  is  being  dispelled  and  no  stronger  or  more 
conservative  statement  of  the  present  concensus  of 
opinion  can  be  cited  than  that  of  Kocher,  who  states  in 
his  recent  book  that  while  he  does  not  go  to  the  length 
of  saying  that  gall-stones  '"belong"  to  the  surgeon,  as 
possession  is  nine  points  of  law,  and  hence  they  are  the 
property  of  the  patient ;  still,  'Tf  the  patient  prefers  to 
wait  in  suffering  and  pain  for  a  stone  to  work  its  way 
down  per  vias  naturales  he  is  but  employing  his  personal 
privileges.  But  in  the  present  day  a  surgeon  is  certainly 
justified  in  telling  a  patient  with  gall-stones  that  by  an 
operation  he  can  be  quickly  and  safely  cured  of  his 
trouble,  and  be  saved  from  an  eventual  danger  more  rap- 
idly and  more  easily  than  by  any  other  treatment." 


*  Read  at  the  meeting  of  the  Tri-State  Medical  Association  of 
the  Carolinas  and  Virginia,  Danville,  Va.,  February,  1904. 

143 


DIAGNOSIS   AND   TREATMENT   OF 

The  results  of  the  work  of  Mayo,  Kehr,  Robson  and 
others  show  that  early  surgery  in  the  biliary  tract,  like 
early  operation  for  appendicitis,  is  safe  and  easy;  while 
late  surgery  is  difficult  and  desperate;  and  lead  to  the 
inevitable  conclusion  that  in  all  cases  of  gall-stones  an 
early  effort  should  be  made  to  restore  health,  rather  than 
a  late  effort  to  save  life. 

The  importance  of  gall-stones  can  only  be  recognized 
after  an  appreciation  of  the  frequency  with  which  the 
disease  exists.  Naunyn,  in  post-mortem  examinations  of 
a  large  number  of  bodies,  found  them  in  io%  of  all  cases. 
The  reason  why  a  diagnosis  of  the  condition  is  not  made 
oftener  is  because  in  85%  of  cases  the  stones  are  quiescent 
and  give  rise  to  no  trouble,  and  in  the  remaining  15% 
of  cases  the  symptoms  originating  from  gall-stones  are 
frequently  misinterpreted  and  attributed  to  gastritis,  in- 
testinal indigestion,  chronic  appendicitis,  loose  kidney  or 
other  causes. 

The  surgeon  who  constantly  bears  in  mind  the  possi- 
bility of  cholelithiasis  in  every  patient  with  obscure 
abdominal  disease,  will  be  the  man  to  make  the  diagnosis 
of  gall-stones  in  the  largest  proportion  of  cases.  Looking 
for  gall-stones  will  not  give  them  to  a  patient,  but  finding 
them  will  usually  bring  relief  through  an  appropriate 
operation. 

Gall-stones  are  usually  secondary  to  infection  of  the 
gall-bladder  with  the  colon  bacillus  or  the  germ  of  typhoid 
fever.  They  are  usually  found  at  or  after  middle  life, 
are  three  times  more  common  in  women  than  in  men, 
and  are  most  often  observed  in  those  who  lead  sedentary 
lives,  wear  tight  clothing  or  eat  to  excess.  The  symptoms 
of   gall-stones    depend   largely   on   the   location  of    the 

144 


GALL   STONES 


stone.  If  the  calculus  is  in  the  gall-bladder  or  cystic  duct 
the  symptoms  are  local,  and  consist  of  spasmodic  pain, 
attended  by  tenderness  in  the  epigastrium,  and  frequently 
distention  of  the  gall-bladder  sufficient  to  make  it  per- 
ceptible on  palpation.  If  the  stone  is  lodged  in  the  hepatic 
or  common  duct  in  addition  to  the  foregoing  local  symp- 
toms there  will  be  constitutional  disturbances,  such  as 
jaundice,  due  to  the  absorption  of  bile  by  the  blood. 

The  diagnosis  of  gall-stones  is  easy  when  there  is 
characteristic  colic,  local  tenderness,  nausea  and  vomiting, 
and  more  or  less  pronounced  jaundice,  but  unfortunately 
the  co-existence  of  these  classical  symptoms  is  rare,  and 
the  surgeon  who  hesitates  to  operate  because  one  or  even 
two  of  them  are  absent  will  fail  to  give  relief  to  many 
patients. 

In  the  record  of  a  large  number  of  cases  where  gall- 
stones were  found  only  one-half  of  the  patients  gave  a 
history  of  biliary  colic  and  only  one-fifth  a  history  of 
marked  jaundice. 

Ochsner,  in  describing  the  symptoms  that  will  most 
constantly  lead  to  the  correct  diagnosis  when  gall-stones 
are  present,  classifies  them  about  as  follows : 

1st.  Digestive  disturbances  such  as  weight  and  burn- 
ing in  the  stomach,  and  distention  of  the  abdomen,  after 
eating. 

2nd.  Dull  pain,  beginning  in  the  epigastric  region,  ex- 
tending to  the  right  along  the  level  of  the  tenth  rib,  and 
distributed  to  the  spine  and  right  shoulder  blade. 

3rd.  Tenderness  upon  pressure  at  a  point  between  the 
umbilicus  and  the  ninth  costal  cartilage  of  the  right  side. 

4th.  History  of  having  had  one  or  more  attacks  of 
typhoid  fever  or  appendicitis. 

5th.     Slight  yellow  discoloration  of  the  skin,  not  suffi- 

145 


DIAGNOSIS    AND    TREATMENT    OF 

cient  to  be  recognized  as  icterus,  but  still  sufficient  to  be 
perceptible  upon  close  inspection. 

6th.    An  increase  in  the  area  of  liver  dullness. 

7th.  A  swelling  of  variable  size  sometimes  seen  op- 
posite the  end  of  the  ninth  rib. 

In  conclusion  Ochsner  says :  *'Of  course  if  we  have 
added  to  these  symptoms  the  biliary  colic,  followed  by 
distinct  jaundice,  and  possibly  the  passage  of  biliary  cal- 
culi, our  diagnosis  is  still  further  confirmed,  but  even 
without  these  three  last  conditions  we  must  make  the 
diagnosis  ordinarily,  or  we  will  miss  the  diagnosis  in  most 
patients  suffering  from  gall-stones." 

It  is  obviously  impossible  in  some  cases  to  make  an 
absolute  diagnosis,  but  the  surgeon  belongs  to  an  un- 
happy branch  of  the  profession  whose  business  it  is  to 
look  for  trouble,  and  when  a  case  is  referred  to  him  with 
symptoms  in  the  region  of  the  liver  that  have  defied 
medical  treatment,  he  should  open  the  abdomen,  ascer- 
tain the  nature  of  the  disease  and  give  relief  by  an  appro- 
priate operation. 

In  following  the  above  practice  I  am  free  to  admit  I 
have  failed  to  find  the  suspected  stone  in  about  one-fourth 
the  cases  operated  on,  but  I  have  never  failed  to  find 
"trouble."  If  there  was  no  stone  there  was  cholecysti- 
tis, flexon  of  the  gall-bladder,  cancer  of  the  liver  or  some 
other  pathologic  condition.  If  there  was  no  operation  to 
be  done  for  stone  there  was  the  equally  important  work 
of  draining  the  gall-bladder  for  infection,  or  suturing  it 
in  a  position  to  correct  angulation  and  prevent  residual 
bile,  or  anastomosing  it  to  the  doudenum  to  overcome  ir- 
remediable obstruction  of  the  common  duct  from  malig- 
nant deposit. 

m6 


GALL   STONES 


Operations  on  the  gall-tract  have  recently  been 
rendered  easier  and  more  accurate  by  an  improved  tech- 
nique. Just  as  the  method  of  exposing  the  kidney  for 
operative  manipulation  has  improved  so  has  the  method 
of  exposing  the  liver.  When  surgeons  first  began  to  do 
work  on  the  kidney  an  incision  was  made  and  the  work 
done  through  it  on  the  wabbling  kidney  beneath.  Now 
the  kidney  is  delivered  through  the  wound  and  the  work 
done  on  it  while  it  is  fixed  in  position  and  under  actual 
inspection.  So,  too,  in  hepatic  surgery.  Formerly  the  in- 
cision was  made  and  the  work  attempted  in  an  inacces- 
sible location.  Now  the  patient  is  placed  on  the  table  in 
a  slightly  reverse  Trendelenburg  position,  with  a  sand 
bag  beneath  the  back,  thus  carrying  movable  viscera  to- 
wards the  pelvis  and  making  the  liver  itself  more  promi- 
nent. An  incision  is  made  beginning  near  the  ninth  costal 
cartilage  of  the  right  side  and  running  vertically  down- 
ward through  the  outer  border  of  the  rectus  muscle.  If 
complications  are  met  with  and  more  working  space  is 
required  the  opening  may  be  enlarged  by  a  second  incision 
beginning  at  the  upper  angle  of  the  first,  and  extending 
obliquely  upward  and  inward  to  the  tip  of  the  ensiform 
cartilage.  This  last  incision  divides  the  skin  and  anterior 
and  posterior  sheaths  of  the  rectus  muscle,  but  does  not 
sever  the  fibres  of  the  rectus  or  the  peritoneum,  as  these 
structures  can  readily  be  stretched  by  a  retracter. 

The  anterior  border  of  the  liver  is  grasped  by  the  right 
hand  of  the  assistant  and  drawn  first  downward  and  then 
outward  until  at  least  one-third  of  the  organ  is  delivered 
into  the  wound.  This  brings  the  gall-bladder  practically 
outside  of  the  body  and  renders  the  ducts  straight  and 
easily  accessible.     After  opening  the  abdomen  the  gall- 

147 


DIAGNOSIS   AND   TREATMENT   OF 

bladder  should  be  carefully  palpated  for  stones.  If  it 
is  tense  with  fluid  it  should  be  emptied  before  being  in- 
cised. If  the  ducts  are  open  this  can  be  accomplished  by 
gentle  but  firm  pressure  against  the  liver.  If  they  are 
closed  the  fluid  must  be  removed  with  a  canula  or  aspira- 
tor. The  gall-bladder  should  be  opened  whether  stones 
are  found  or  not,  as  it  may  contain  biliary  sand,  thick 
tarry  bile,  or  be  chronically  inflamed,  and  hence  require 
drainage. 

Before  making  the  incision  into  the  gall-bladder  the 
general  peritoneal  cavity  should  be  carefully  protected 
from  contamination  by  a  well  placed  coffer  dam  of  gauze. 
This  can  be  effectively  done  by  taking  a  piece  of  gauze 
two  yards  long,  folding  it  into  a  strip  the  width  of  the 
hand  and  rolling  it  into  a  bandage.  This  is  unrolled  and 
systematically  packed  in  the  abdomen,  beginning  at  the 
left  side  of  the  gall-bladder,  then  beneath  it  and  finally 
to  its  right. 

The  incision  in  the  gall-bladder  should  be  in  the  fun- 
dus and  of  sufficient  size  to  introduce  the  index  finger. 
Stones  found  in  its  cavity  should  be  removed  with  a 
scoop  devised  for  the  purpose  or  with  a  dull  uterine 
curette. 

The  question  of  the  patency  of  the  cystic,  hepatic  and 
common  ducts  will  next  have  to  be  determined.  It  is  well 
to  bear  in  mind  that  they  may  contain  a  stone  and  still 
be  capable  of  transmitting  bile,  and  again  that  they  may 
contain  no  stone  but  be  temporarily  occluded  by  swelling 
of  their  mucosa. 

There  is  no  well  determined  procedure  to  settle  this 
important  point.  Some  surgeons  rely  largely  on  the  pa- 
tient's previous  history,  but  this  is  uncertain,  as  Kehr  has 

148 


GALL   STONES 


found  stone  in  the  common  duct  in  a  large  number  of 
cases  that  had  never  manifested  jaundice.  Other  opera- 
tors endeavor  to  pass  a  probe  through  the  ducts,  but 
this  is  a  bad  practice,  as  experiments  in  the  dead  house 
show  that  a  probe  will  not  pass  through  the  normal  cystic 
duct,  owing  to  a  valve  like  arrangement  of  the  mucous 
lining.  Fergusson  and  Van  Hook  endeavor  to  inject 
water  or  air  through  the  ducts,  but  this  method  is  time 
consuming,  requires  special  apparatus  and  endangers 
sepsis.  Weir  adopts  the  plan  of  dropping  a  pellet  of 
methylene  blue  in  the  gall-bladder  just  as  he  completes 
the  operation,  stating  that  if  the  ducts  are  open  the 
coloring  agent  passes  into  the  intestines  and  stains  the 
feces,  but  if  the  ducts  are  closed  the  result  is  negative. 
The  method  is  safe  and  ingenious  but  does  not  help  to 
solve  the  problem  while  the  patient  is  on  the  table. 

Practically  the  best  that  can  be  done  is  to  palpate  the 
ducts  carefully  and  systematically  from  their  origins  in 
the  gall-bladder  and  liver  to  their  termination  in  the 
duodenum,  which  can  be  satisfactorily  done  by  introduc- 
ing two  forefingers  into  the  foramen  of  Winslow,  behind 
the  ducts,  and  making  pressure  on  them  with  the  thumb 
from  the  front.  If  a  stone  is  found  it  should  be  removed 
by  incising  the  duct;  if  one  can  not  be  detected  the  duct 
should  be  left  intact. 

Owing  to  the  varying  location  of  gall-stones  and  to  the 
many  complications  that  result,  a  great  number  of  opera- 
tions have  been  devised  to  meet  the  different  conditions 
encountered.  Gall-tract  surgery  is  young  compared  with 
surgery  of  the  pelvis  and  of  the  appendix,  and  the  indi- 
cations for  certain  methods  have  not  yet  been  definitely 
settled. 

149 


DIAGNOSIS   AND   TREATMENT    OF 

Cholecystotomy  consists  in  the  incision  of  the  gall-blad- 
der, the  removal  of  its  contents  and  the  immediate  closure 
by  suture  of  the  opening  in  the  viscus.  The  operation  is 
indicated  for  stones  in  a  healthy  gall-bladder  with  unob- 
structed ducts.  It  is  called  the  "ideal  operation"  by  its 
advocates  and  the  same  term  is  applied  to  it  satirically  by 
its  opponents.  The  cases  in  which  it  is  safe  to  apply  the 
method  are  very  exceptional. 

Cholecystendesis  consists  in  the  steps  described  in  the 
operation  of  cholecystotomy,  except  that  in  place  of  drop- 
ping the  gall-bladder  back  in  the  abdomen,  the  fundus  is 
anchored  by  sutures  to  the  abdominal  incision.  The  ob- 
ject is  either  to  correct  flexion  or  to  place  the  organ  in 
such  a  position  that  it  will  be  accessible  in  case  it  is  found 
necessary  to  open  and  drain  it. 

Cholecystostomy  consists  in  the  incision  of  the  gall-blad- 
der, the  removal  of  its  contents  and  the  subsequent  drain- 
age of  its  cavity  through  the  abdominal  incision.  The 
fistulous  opening  may  be  formed  either  by  sewing  the  cut 
edge  of  the  gall-bladder  to  the  parietal  peritoneum  with 
chromicised  catgut,  or  preferably,  by  tying  a  tube  in  the 
opening  of  the  gall-bladder  with  a  purse  string  suture  and 
bringing  it  through  the  abdominal  incision,  either  trusting 
to  adhesions  forming  around  the  tube  before  its  detach- 
ment, or  bringing  the  gall-bladder  in  contact  with  the 
under  surface  of  the  wound  by  two  suspension  ligatures. 
The  operation  of  cholecystostomy  is  indicated  in  gall- 
stones complicated  by  acute  or  chronic  cholecystitis  and  is 
the  method  applicable  to  the  majority  of  cases.  It  pre- 
vents accumulation  of  fluid  in  the  diseased  viscus,  affords 
exit  for  an  overlooked  stone,  and  cures  inflammation  of 


GALL    STONES 


the  gall-bladder  and  ducts  by  providing  free  and  pro- 
longed drainage. 

Cholecystectomy  consists  of  the  removal  of  the  entire 
gall-bladder.  The  operation  can  be  done  with  compara- 
tive ease  if  the  cystic  duct  be  first  ligated  and  divided,  and 
the  viscus  freed  from  the  attachment  to  the  liver  from 
behind  forwards.  The  indications  for  the  operation  are 
yet  unsettled.  There  is  no  doubt  that  it  can  be  done  with 
low  mortality,  but  the  question  is  as  to  the  ultimate  re- 
sults that  follow  it.  Davis,  of  Omaha,  and  others  claim 
that  it  avoids  a  fistula  with  the  attending  long  convales- 
cence, removes  a  useless  organ,  prevents  the  possibility  of 
stones  reforming,  and  gives  the  patient  the  best  guaran- 
tee of  complete  restoration  to  health.  Richardson,  of 
Boston,  at  one  time  an  enthusiastic  advocate  of  the  opera- 
tion, now  condemns  it  except  in  selected  cases,  as  the  re- 
moval of  the  gall-bladder  prevents  its  utilization  as  a 
drainage  tract,  and  patients  after  the  operation  frequent- 
ly have  a  recurrence  of  symptoms  which,  owing  to  the  ab- 
sence of  the  gall-bladder,  he  is  at  a  loss  to  know  how  to 
re-relieve.  A  conservative  statement  of  the  present  opin- 
ion of  the  profession  in  regard  to  cholecystectomy  is  that 
the  operation  should  be  limited  to  cases  of  irremedial 
obstruction  of  the  cystic  duct,  and  to  cases  of  gangrene 
or  malignant  disease  of  the  walls  of  the  gall-bladder. 

Choledochotomy  consists  in  the  incision  of  the  common 
duct  for  the  removal  of  a  stone.  The  term  is  also  some- 
times used  to  describe  incision  of  the  other  bile  ducts. 
When  the  stone  is  lodged  at  the  opening  of  the  common 
duct  into  the  intestine  it  is  best  reached  by  ^IcBurney's 
trans-duodenal  route ;  otherwise  it  is  more  accessible  by 
approaching  the  duct  by  the  external  route  to  the  right 

151 


GALL   STONES 


of  the  duodenum.  An  incision  is  made  in  the  duct  parallel 
to  its  long  axis  and  the  stone  removed  either  complete  or 
fragmented.  Halstead  and  others  advise  suture  of  the 
opening,  but  the  majority  of  surgeons  state  that  this  pro- 
cedure is  unnecessary,  and  the  present  practice  is  sim- 
ply to  drain  Morrison's  pouch  with  a  tube  and  gauze. 

Cholecystenterostomy  consists  in  the  anastomosis  of 
the  fundus  of  the  gall-bladder  to  the  duodenum,  preferab- 
ly by  means  of  Murphy's  button.  The  operation  is  in- 
dicated for  irremedial  obstruction  of  the  common  duct 
from  cancer  or  other  causes,  and  relieves  jaundice  by  af- 
fording a  new  avenue  by  which  bile  can  pass  from  the 
liver  to  the  intestinal  canal. 


IS2 


Analysis  of  the 

Last  Fifty  Cases  of  Goitre  Operated  On 

at  St.   Luke's  Hospital  * 

Nineteen  years  ago  when  the  University  College  of 
Medicine  was  established  I  was  appointed  assistant  to 
my  father,  and  my  principal  duty  was  to  provide  material 
for  his  weekly  clinic.  On  two  or  three  occasions  I  had 
a  case  of  goitre  for  him,  but  he  always  found  some  excuse 
for  not  operating.  Finally  one  night  he  called  me  into 
his  office  and  said :  "Stuart,  don't  give  me  any  more 
cases  of  goitre  in  my  clinic.  I  once  operated  on  a  case 
and  it  was  the  most  bloody,  barbarous  and  unsurgical 
procedure  I  ever  attempted.  Every  man  must  be  taught 
by  his  own  experience,  but  if  there  is  one  thing  you  can 
learn  from  me  it  is  not  to  operate  for  goitre." 

This  advice  was  good  for  its  day  and  generation.  The 
great  Kocher's  mortality  in  his  first  seventy  cases  of 
simple  goitre  was  40  per  cent.,  and  Charles  H.  Mayo's 
mortality  in  his  first  sixteen  cases  of  ex-ophthalmic  goitre 
was  25  per  cent.  It  is  no  wonder  that  at  one  time  the 
operation  was  regarded  as  unwarranted  by  the  majority 
of  surgeons,  and  it  is  not  surprising  that  there  are  still 
to-day  some  among  the  older  practitioners  who  hesitate 
to  advise  a  patient  with  goitre  to  seek  operative  relief 
except  as  a  last  resort. 

Times  have  changed  and  the  once  formidable  opera- 


*  Read   at   the   meeting   of   the    Medical    Society   of    Virginia, 
Richmond,  Va.,  October,  191 1. 

153 


CASES  OF  GOITRE  OPERATED  ON 

tion  has  been  rendered  comparatively  simple  and  safe  in 
experienced  hands.  Kocher,  with  a  courage  that  seems 
marvelous  to  the  present  generation  of  surgeons,  per- 
severed in  his  work  until  he  finally  established  a  tech- 
nique that  has  reduced  the  mortality  in  his  last  one  thou- 
sand operations  for  goitre  to  four-tenths  of  one  per  cent. 
This  was  accomplished  by: 

1.  Early  operations  on  more  favorable  cases. 

2.  Improved  aseptic  methods  to  prevent  infection. 

3.  More  skillful  administration  of  anesthetics. 

4.  An  exposure  which  gave  ability  to  control  hemor- 
rhage and  avoid  injury  to  certain  important  structures 
of  the  neck. 

Six  or  seven  years  ago  I  became  convinced  from 
Kocher's  writings  that  the  operation  of  partial  thyroidec- 
tomy was  advisable  in  certain  conditions.  I  have  now 
operated  on  more  than  one  hundred  cases  of  goitre,  em- 
bracing practically  all  types  of  the  disease  without  a  single 
death  and  with  most  satisfactory  symptomatic  results. 

Despite  the  low  mortality  of  the  operation,  as  reported 
by  numerous  surgeons,  I  do  not  think  a  patient  should 
be  treated  surgically  until  medical  measures  have  been 
tried  and  proven  to  be  inefficient.  From  personal  obser- 
vation I  am  satisfied  that  at  least  one-half  of  all  patients 
suflfering  with  both  simple  and  ex-ophthalmic  goitre  will 
get  well  without  operation.  Whether  their  recovery  is 
due  to  the  remedies  prescribed  by  the  physician  or  to 
the  inherent  tendency  of  the  system  to  overcome  an  ab- 
normality is  not  a  material  question.  The  practical  fact 
is  that  these  patients  should  be  treated  along  accepted 
lines  and  given  a  reasonable  time  to  see  what  Nature 
will  do  for  them  before  they  are  subjected  to  a  surgical 

154 


AT  ST.  LUKES  HOSPITAL 


risk.  If,  however,  they  fail  to  improve  or  their  symp- 
toms get  worse,  then  an  operation  should  be  advised  be- 
fore complications  develop,  or  incurable  structural 
changes  occur  in  the  heart,  eyes  or  other  organs.  In 
other  words,  the  surgeon  should  not  operate  on  a  case 
too  soon,  and  the  physician  should  not  treat  a  case  too 
long.  It  is  a  pity  that  there  is  not  a  better  understanding 
between  the  physician  and  the  surgeon  in  the  treatment 
of  the  disease,  as  each  has  a  distinct  and  separate  field 
of  work,  and  each  accomplishes  results  the  other  could 
not  hope  to  secure. 

The  surgeon  should  not  underestimate  the  value  of 
medical  treatment.  He  should  remember  he  sees  only 
the  cases  in  which  failure  has  resulted  and  is  ignorant 
of  the  cases  in  which  cures  have  been  effected.  On  the 
other  hand,  the  physician  should  not  criticise  the  sur- 
geon for  operating  on  so  many  patients.  He  should  re- 
member that  practically  all  his  cases  have  been  treated 
medically  without  success  and  have  been  referred  to  him 
because  they  could  not  be  cured  without  the  use  of  the 
knife. 

The  medical  treatment  of  simple  goitre  consists  in  plac- 
ing the  patient  under  the  best  possible  hygienic  conditions. 
This  is  especially  the  case  in  the  symmetrical  enlarge- 
ment of  the  thyroid  gland  which  is  frequently  seen  in 
girls  about  the  age  of  puberty.  The  patient  should  have 
proper  food,  pure  drinking  water  and  an  abundance  of 
fresh  air.  Regular  hours  of  rest  should  be  prescribed 
and  over-exertion  and  mental  excitement  carefully 
guarded  against.  In  the  parenchymatous  type  of  the  dis- 
ease the  internal  administration  of  an  active  preparation 

155 


CASES  OF  GOITRE  OPERATED  ON 

of  thyroid  extract  does  much  good.  If  it  fails,  arsenic 
and  iodide  of  potash  should  be  tried.  The  local  use  of 
tincture  of  iodine,  especially  when  applied  with  catapho- 
resis,  is  a  remedy  of  recognized  value.  As  simple  goitre 
causes  mechanical  symptoms,  the  patient  is  often  the  best 
judge  as  to  when  the  disfigurement  or  discomfort  it  pro- 
duces is  sufficient  to  justify  an  operation.  The  danger 
of  malignant  degeneration,  however,  must  not  be  left 
out  of  consideration. 

The  medical  treatment  of  ex-ophthalmic  goitre  con- 
sists primarily  in  rest.  If  possible,  the  patient  should  be 
placed  in  a  hospital  and  for  a  time  confined  to  bed.  An 
ice-bag  over  the  heart  is  often  of  temporary  benefit. 
Roger's  and  Beebee's  serum  gives  good  results  in  selected 
cases  and  should  be  used  where  indicated.  Forcheimer 
reports  cures  from  neutral  preparation  of  hydro-bromate 
of  quinine.  He  advises  that  it  be  given  four  times  a 
day  in  five-grain  doses.  If  there  is  no  improvement  in 
forty-eight  hours  he  adds  one  grain  of  ergotin  to  each 
capsule.  Belladonna  given  hypodermically  in  the  form 
of  atropia  is  a  remedy  of  recognized  value.  X-Ray 
exposures  sometimes  result  in  marked  benefit  when  every- 
thing else  fails.  The  local  use  of  iodine  and  the  internal 
administration  of  thyroid  extract  are,  of  course,  to  be 
avoided. 

If  medical  treatment  fails  to  effect  a  cure  in  a  reason- 
able time,  then  the  case  should  be  treated  surgically. 
Delay  is  more  dangerous  in  exophthalmic  than  in  simple 
goitre  as  the  symptoms  are  not  due  to  pressure  but  to 
poison,  and  if  hyperthyroidism  is  permitted  to  continue 

156 


AT  ST.  LUKES  HOSPITAL 


there  will  be  both  increased  risk  and  less  satisfactory 
results  from  the  operation. 

If  it  is  decided  to  do  a  partial  thyroidectomy,  it  is  not 
well  to  tell  the  patient  in  advance  the  day  and  hour  fixed 
for  the  operation.  In  some  cases  where  there  is  great 
fear  of  the  operation  it  may  be  proper  to  practice  the 
method  of  Crile  which  he  calls  "stealing  the  gland." 
The  patient  is  told  that  before  resorting  to  an  operation 
it  has  been  deemed  best  to  try  the  "Inhalation  Treatment." 
Every  day  at  a  certain  hour  the  anesthetist  goes  to  the 
patient's  room,  places  a  mask  over  his  face  and  for  ten 
minutes  allows  him  to  inhale  some  one  of  the  essential 
oils,  such  as  eucalyptus.  The  day  set  for  the  operation, 
the  relatives,  of  course,  being  informed  of  what  is  to 
take  place,  the  treatment  is  given  as  usual,  only  ether  or 
chloroform  is  slowly  substituted  for  the  oil  and  the 
patient  put  to  sleep  without  knowledge  that  the  operation 
will  be  done  that  day. 

The  operation  is  most  conveniently  and  safely  per- 
formed with  the  table  in  a  reverse  Trendelenburg  posi- 
tion. The  elevation  of  the  patient's  head  causes  a  certain 
degree  of  anaemia  which  reduces  the  tendency  to  bleed 
and  lessens  the  amount  of  the  anesthetic  necessary  to  pro- 
duce unconsciousness. 

A  transverse  collar  incision  is  made  through  the  skin 
and  platysma  over  the  most  prominent  part  of  the  goitre, 
and  these  two  structures  reflected  to  expose  the  under- 
lying muscles.  The  sterno-hyoids  and  sterno-thyroids 
are  separated  in  the  middle  line  to  expose  the  gland.  This 
may  give  sufficient  room  to  permit  the  delivery  of  the 
tumor,  but  often  it  is  necessary  to  divide  the  muscles 

157 


CASES  OF  GOITRE  OPERATED  ON 

transversely  near  their  upper  insertion  in  order  to  give 
a  safe  working  field. 

If  the  goitre  is  of  the  circumscribed  variety,  the  en- 
capsulated mass  should  be  enucleated,  the  bleeding  ar- 
rested and  the  cavity  closed  by  buried  sutures.  If  the 
goitre  is  of  the  diffuse  variety,  the  affected  lobe  and 
isthmus  should  be  excised  by  ligating  the  superior  and 
inferior  thyroid  arteries  and  dissecting  it  from  the  pos- 
terior capsule. 

Hemorrhage  should  be  minimized  by  catching  vessels 
before  or  immediately  after  division.  Removal  of  the 
parathyroids  should  be  avoided  by  preservang  the 
posterior  capsule  which  covers  them.  Injury  to  the  recur- 
rent laryngeal  nerve  should  be  guarded  against  by  care- 
fully exposing  the  inferior  thyroid  artery  and  ligating  it 
close  to  the  pole. 

After  tying  all  bleeding  points,  drainage  should  be 
inserted,  the  divided  muscles  sutured  and  the  skin  neatly 
approximated. 

In  order  to  bring  out  some  interesting  and  practical 
facts  with  reference  to  goitre,  I  have  made  a  brief  analy- 
sis of  the  last  fifty  cases  operated  on  at  St.  Luke's  Hos- 
pital. As  only  white  patients  are  admitted  to  the  insti- 
tution nothing  with  regard  to  the  influence  of  race  on 
the  occurrence  of  the  disease  can  be  deduced.  I  am 
satisfied,  however,  from  my  experience  in  other  hospitals 
that  goitre  develops  as  frequently  in  the  negro  as  in  the 
Caucasian. 

The  fifty  cases  came  from  six  different  states.  The 
number  is  so  few  and  the  territory  covered  so  large  that 
no  conclusions  are  possible  with  reference  to  the  influence 

158 


AT  ST.  LUKES  HOSPITAL 


of  geographical  location.     Four-fifths  of  the  cases  came 
from  cities  of  10,000  population,  or  over. 

Of  the  patients,  seven  were  men  and  forty-three  were 
women,  showing  that  the  disease  is  more  frequent  in  the 
female.  The  youngest  patient  was  seventeen  and  the 
oldest  sixty-one,  the  average  age  being  thirty,  showing 
that  it  is  a  disease  of  middle  life. 

Thirty-one  cases  were  simple  goitre,  causing  only 
mechanical  symptoms.  Nineteen  were  of  the  ex-ophthal- 
mic type  attended  by  marked  symptoms  of  hyperthy- 
roidism. The  proportion  of  the  latter  to  the  former  is 
much  greater  than  usually  reported  and  shows  that  the 
profession  in  my  territory  is  not  yet  educated  to  the 
point  of  referring  early  and  easy  cases  to  the  surgeon, 
but  as  yet  only  send  the  patient  whose  need  is  urgent. 

In  thirty-six  cases  the  operation  was  on  the  right  lobe, 
in  seven  on  the  left,  and  in  seven  on  both  lobes. 

The  greater  frequency  of  the  disease  on  the  right  side 
of  the  thyroid  as  compared  to  the  left  is  noted  by  all 
observers,  but  so  far  no  satisfactory  explanation  on  either 
anatomical  or  physiological  lines  has  been  given. 

The  anesthetic  employed  was  cocaine  in  one  case,  chlo- 
roform in  thirty  cases  and  ether  in  nineteen  cases. 
Cocaine  was  used  in  the  one  instance  because  the  patient 
was  obese,  had  a  bad  heart  and  protested  against  taking 
a  general  anesthetic.  Chloroform  and  ether  were  used 
in  the  other  forty-nine  cases. 

From  careful  observation  I  am  convinced  that  patients 
with  goitre  take  a  general  anesthetic  as  well  as  any  other 
class  of  cases  and,  as  the  operation  can  be  done  more 
rapidly  and  thoroughly  with  less  strain  on  the  patient 
and  the  surgeon,  I  advocate  its  use  unless  there  be  some 

159 


CASES  OF  GOITRE  OPERATED  ON 

special  contraindication.  Whether  the  agent  employed 
be  chloroform  or  ether  should  be  decided  not  by  consid- 
ering the  anesthetic  but  the  anesthetist.  In  the  first  of 
the  series  reported  I  employed  a  man  who  had  great 
experience  in  giving  chloroform.  He  left  my  service  and 
was  replaced  by  a  woman  who  had  long  training  in  the 
administration  of  ether.  In  the  hands  of  experts  I  found 
both  agents  safe  and  satisfactory. 

In  the  fifty  cases  reported,  fourteen  operations  were 
enucleations  of  circumscribed  tumors,  and  thirty-six  were 
excisions  of  enlarged  lobes.  The  amount  of  the  gland 
removed  varied  from  a  slightly  enlarged  lobe  weighing 
one  or  two  ounces  to  a  huge  mass  weighing  seven  pounds. 
The  average  time  taken  to  complete  an  operation  was 
thirty  minutes.  The  average  9onfinement  of  the  patient 
to  bed  was  seven  days  and  the  average  stay  in  the  hos- 
pital was  two  weeks. 

The  Post-Operative  Complications  were  as  Follows : — 
One  patient  had  huskiness  of  the  voice  for  a  week  or 
ten  days,  showing  I  had  irritated  but  not  permanently 
injured  the  recurrent  laryngeal  nerve. 

One  patient  had  infection  of  the  wound  due  to  the  im- 
perfect drainage  of  a  large  cavity  left  after  the  dislocation 
of  an  intrathoracic  goitre. 

One  patient  had  a  severe  hemorrhage  shortly  after  re- 
covery from  the  anesthetic,  requiring  the  wound  to  be 
reopened  and  the  bleeding  arrested.  This  accident  was 
probably  due  to  including  some  muscular  tissue  in  one 
of  the  ligatlures,  which  contracted  and  pulled  the  suture 
off. 

Two  patients  had  hyperthyroidism,  one  mildly,  the 
other  severely.    They  both  recovered  in  forty-eight  hours 

i6o 


AT  ST.  LUKES  HOSPITAL 


Whether  the  symptoms  were  due  to  absorption  of  the 
thyroid  juices  from  the  wound  or  whether  they  were  due 
to  ''psychic  excitation,"  as  claimed  by  Crile,  I  do  not  know 
The  surgeon  should  try  to  minimize  the  frequency  and 
severity  of  this  complication  by  handling  the  gland  gently 
during  the  operation  to  avoid  expressing  its  juices,  and 
also  by  endeavoring  to  allay  the  patient's  fear  before  the 
operation  to  avoid  the  possibility  of  hypersecretion  from 
psychic  influences.  If  pain,  fright  or  mental  emotions 
are  capable  of  causing  hyperthyroidism,  it  is  an  argu- 
ment in  the  favor  of  the  use  of  a  general  anesthetic. 

Not  long  ago  I  had  a  case  at  the  Virginia  Hospital 
which  strongly  substantiated  Crile's  theory.  The  patient 
was  a  woman  on  whom  I  had  operated  two  years  before 
for  ex-ophthalmic  goitre  and  had  effected  a  symptomatic 
cure.  She  came  back  to  the  hospital  for  the  repair  of  the 
perineum  and  the  correction  of  a  displacement.  When 
the  time  came  for  the  operation  she  tried  to  back  out,  but 
I  urged  her  on,  and  she  went  to  the  anesthetizing  room 
in  a  bad  state  of  fright.  The  operation  was  simple  and 
uncomplicated,  but  in  a  few  hours  she  developed  high 
fever,  was  wildly  delirious  and  her  heart  was  so  rapid 
that  her  pulse  could  not  be  counted.  Here  was  a  clear 
instance  of  hyperthyroidism  developing  from  the  exces- 
sive secretion  of  the  thyroid  gland  stimulated  by  the 
patient's  psychic  condition.  In  this  case  there  was  no 
possibility  of  thyroid  juices  being  absorbed  by  fresh  sur- 
faces as  the  operation  was  not  on  the  neck  but  in  the 
pelvis. 

The  final  results  of  the  operations  were  as  follows: — 
In  thirty-one  cases  of  simple  goitre  where  the  symptoms 

i6i 


CASES  OF  GOITRE  OPERATED  ON 

were  due  to  mechanical  pressure,  there  was  complete 
relief  in  every  instance. 

In  the  nineteen  cases  of  ex-ophthalmic  goitre  where 
the  symptoms  were  due  to  hyperthyroidism,  there  was 
symptomatic  cure  in  sixteen  cases,  marked  benefit  in  two 
cases  and  failure  to  receive  any  benefit  in  one  case. 

In  stating  that  a  symptomatic  cure  was  afifected  in  six- 
teen cases,  I  mean  that  the  patients  were  relieved  of 
nervousness,  tremor,  tachycardia,  and  digestive  disturb- 
ances and  that  they  regained  their  usual  weight,  strength 
and  spirits.  The  ex-ophthalmos  was  improved  in  a  few 
of  the  early  cases,  but  remained  as  a  permanent  disfigure- 
ment in  the  majority  of  instances.  All  of  the  patients 
still  seem  to  have  some  irritability  of  the  nervous 
mechanism  regulating  the  heart,  for  while  the  pulse  rate 
is  normal  under  usual  conditions  it  temporarily  becomes 
abnormally  rapid  on  unusual  excitement  or  exertion. 

In  the  two  cases  reported  improved  but  not  cured,  the 
symptoms  all  continue  but  in  much  less  intensity.  Failure 
to  effect  a  cure  was  due  to  not  removing  enough  of  the 
thyroid  gland.  If  in  the  future  the  patients  are  not  satis- 
fied with  their  condition  a  second  operation  can  be  done. 

The  amount  of  the  thyroid  secretion  is  not  dependent 
on  the  anatomical  bulk  but  on  the  physiological  activity 
of  the  glandular  tissue ;  hence,  in  every  case  it  is  a  ques- 
tion with  the  surgeon  of  how  much  to  take  out  and  how 
much  to  leave  in.  If  an  error  is  made  it  had  better  be 
on  the  side  of  conservatism  as  it  is  easy  to  take  out  more 
and  impossible  to  put  back  any  of  this  tissue  which  has 
such  an  important  effect  on  the  physical  nutrition  and  ner- 
vous equilibrium  of  the  individual.  Personally,  however, 
I  must  say  that  with  increasing  experience  I  find  myself 

162 


AT  ST.  LUKES  HOSPITAL 


taking  out  more  and  more  of  the  gland  and  have  never 
seen  any  bad  results. 

In  the  one  case  reported  where  the  patient  received  no 
benefit,  the  fault  was  in  the  diagnosis,  not  in  the  treat- 
ment, as  the  case  was  not  one  of  hyperthyroidism  but  of 
neurasthenia.  The  patient  was  a  woman  of  thirty-two, 
referred  to  me  by  a  prominent  specialist  of  this  city.  She 
had  very  prominent  eyes  and  a  goitre  the  size  of  a  lemon. 
She  was  nervous,  tremulous  and  suffered  with  tachycar- 
dia on  slight  exertion.  I  operated  on  her  and  removed 
the  right  lobe  and  the  isthmus.  My  pathologist  ex- 
amined the  specimen  and  reported  that  the  tissue  did  not 
show  the  cellular  hyperplasia  usually  seen  in  hyperthy- 
roidism, and  he  believed  it  was  a  case  of  simple  goitre.  A 
more  careful  review  of  the  patient's  history  and  symp- 
toms made  it  apparent  that  the  woman  was  a  victim  of 
neurasthenia  and  the  goitre  was  but  a  coincident  trouble. 
Failure  to  secure  the  expected  benefit  from  the  opera- 
tion was  a  further  corroborative  evidence. 


163 


The  Thyroid  and  Hyperthyroidism 

A  review  of  the  history  of  surgery  will  show  that  at 
certain  periods  special  study  has  been  concentrated  on  a 
single  organ.  Disease  of  the  pelvic  organ,  of  the  appendix 
vermiformis,  of  the  liver  and  gall-tract,  of  the  stomach 
and  of  the  pancreas,  have  each  in  turn  occupied  the  pro- 
fessional mind.  At  present  the  thyroid  gland  is  the  or- 
gan chiefly  under  consideration. 

Much  has  been  learned  about  its  physiological  func- 
tion and  pathological  changes,  but  much  is  yet  unknown. 
Brilliant  results  have  been  achieved  in  treating  patients 
the  victims  of  its  diseases,  but  they  have  been  obtained 
by  relieving  the  symptoms  rather  than  by  removing  the 
cause,  or  at  the  cost  of  a  mutilating  operation.  The  day 
will  come  when  a  satisfactory  knowledge  of  the  etiology 
of  thyroid  disease  will  enable  us  either  to  prevent  its  oc- 
currence or  to  cure  it  by  some  less  heroic  measure  than 
the  violence  of  surgery,  but  the  time  is  not  yet. 

From  the  conception  of  Claude  Bernard  of  subtle 
agents  known  as  internal  secretions,  down  to  the  demon- 
stration of  the  existence  and  composition  of  iodothyrin, 
the  history  of  the  thyroid  gland  has  received  many  valu- 
able, and  some  dramatic,  contributions. 

Paracelsus,  in  the  seventeenth  century,  recognized  the 
relationship  between  goitre  and  cretinism. 

Schiff,  in  1856,  showed  that  complete  thyroidectomy 
was  followed  by  the  death  of  the  animal. 


*  Oration  on  Surgery  delivered  at  the  meeting  of  the  Southern 
Medical  Association,  Jacksonville,  Fla.,  November,   1912. 

i6s 


THE  THYROID  AND  HYPERTHYROIDISM 


Gull,  in  1873,  described  the  symptoms  of  myxedema. 
Sandstroem,    in     1880,     discovered    the    parathyroid 
glands,  but  did  not  distinguish  their  physiological  impor- 
tance. 

Kocher,  in  1882,  demonstrated  the  fact  that  myxede- 
ma would  develop  after  removal  of  the  thyroid. 

Moebius,  in  1886,  crystallized  the  work  of  Parry, 
Graves  and  Basedow,  and  proved  that  the  syndrome  pre- 
viously described  by  them  and  believed  to  be  a  disease 
of  the  nervous  system,  was  really  caused  by  excessive 
thyroid  secretion. 

Gley,  in  1891,  separated  the  functions  of  the  thyroid 
and  parathyroids  and  proved  that  tetany  following  an 
operation  was  due  to  the  loss  of  the  parathyroids. 

Baumann,  in  1896,  isolated  a  body  containing  iodine, 
possessing  the  physiological  characteristics  of  the  thyroid. 
To  this  substance  he  gave  the  name  iodothyrin. 

McCallum  and  Voegtlin,  in  1908,  proved  the  import- 
ance of  the  parathyroids  in  the  control  of  calcium  meta- 
bolism. 

Such,  in  brief,  are  the  more  profound  and  epoch- 
making  advances  made  in  the  study  of  the  gland.  They 
constitute  a  series,  beautiful  in  its  logical  evolution,  pro- 
found in  its  import  to  human  welfare. 

The  function  of  the  thyroid  is  carried  out  by  an  in- 
ternal secretion.  It  reaches  the  general  system  of  lym- 
phatics, and  its  most  important  element  has  been  demon- 
strated in  the  blood.  The  colloid  material  found  in  the 
follicles  is  regarded  by  some  of  the  best  authorities  as 
peculiar  to  this  gland.    Chemically  it  is  made  up  of  iodo- 

166 


THE  THYROID  AND  HYPERTHYROIDISM 

thyrin  and  thyro-albumin,  the  latter  a  nucleo-proteid  con- 
taining no  iodine,  but  rich  in  phosphorous. 

lodothyrin  is  a  combination  of  a  globuHn  with  iodine. 
The  compound  is  not  found  elsewhere  save  in  the  blood, 
where  it  may  be  regarded  as  directly  derived  from  the 
gland.  It  is  not  at  all  certain  that  iodothyrin  represents 
the  total  of  the  active  principles  of  the  thyroid,  but  it  is 
at  least  true  that  its  administration  produces  much  the 
same  effect  as  does  the  extract  of  the  gland  in  the  treat- 
ment of  myxedema. 

The  thyroid  gland  is  essential  to  life.  Whatever  be 
the  nature  of  its  control  over  body  metabolism,  it  is  a 
vital  one.  Kocher  states  that  an  individual  deprived  of 
the  thyroid  may  live  seven  years.  So  quietly  and  modest- 
ly does  this  important  organ  do  its  work  that  the  exact 
part  it  plays  is  still  hidden.  But  it  naturally  lies  some- 
where between  the  two  extremes,  hypo  and  hyper-thyroid- 
ism.  The  former  is  seen  upon  removing  the  gland,  leav- 
ing the  parathyroids,  the  latter  by  feeding  thyroid  ex- 
tract. 

Thyroidectomy  produces  symptoms  of  a  chronic  cach- 
exia. The  metabolism  of  the  body  is  depressed,  heat 
regulation  and  gaseous  interchange  are  at  a  low  ebb.  In 
the  young  growth  is  lessened  and  the  skeletal  system  is 
dwarfed.  The  cells  fail  to  reach  their  proper  develop- 
ment and  the  connective  tissue  remains  myxomatous,  giv- 
ing to  the  skin  a  dry,  massive,  elephantile  appearance. 
The  hair  is  coarse  and  shows  deficient  nourishment.  The 
nervous  system  halts  in  development,  and  mentality  does 
not  rise  above  the  level  of  the  infant.  Physically  and  in- 
tellectually the  victim  of  thyroid  poverty  is  less  a  man, 
more  a  beast. 

167 


THE  THYROID  AND  HYPERTHYROIDISM 

At  the  other  end  of  the  scale  stands  the  exophthalmic. 
Excessive  feeding  with  thyroid  extract  produces  symp- 
toms of  metabolic  riot.  Heat  production  and  gaseous 
interchange  are  rapid.  The  body  tissues  are  stimulated 
to  a  course  of  wasting  dissipation.  There  are  seen  trem- 
or, sweating,  tachycardia,  muscular  weakness,  loss  of 
weight  and  feverish  mental  activity.  The  evidence  of 
thyroid  excess  suggests  the  entrance  of  tragedy  into  the 
life  of  its  subject. 

The  thyroid  gland,  then,  has  a  special  influence  on  the 
nervous  system,  the  muscular  system,  the  skin  and  epi- 
thelial structures,  the  osseous  system,  and  on  the  sexual 
functions.  It  exercises  a  general  influence  on  the  meta- 
bolism of  the  body.  Of  the  various  hypotheses  that  have 
been  advanced  to  explain  its  action,  it  is  impossible  at 
this  time  to  say  which  is  the  true  one.  It  may  be  that 
each  contains  an  element  of  truth;  it  is  not  likely  that 
all  are  wide  of  the  mark.  But,  either  as  a  neutralizer  of 
endogenous  toxins,  or  as  a  hormone  stimulating  other  or- 
gans and  tissues  to  activity,  or  by  some  other  obscure  but 
potent  influence  the  thyroid  is  a  pace-maker  for  the  body. 

It  is  a  temptation  to  speculate  as  to  what  the  future 
may  have  to  tell  of  the  thyroid  and  other  ductless  glands. 
Who  can  say  how  far  the  influence  of  these  organs  may 
be  shown  to  parallel  the  lines  of  the  great  social  hier- 
archy? Who  can  say  that  the  dullard,  the  drone  and  the 
vast  army  of  the  inefficient  and  dependent  are  not,  after 
all,  but  close  cousins  to  the  cretin  or  can  deny  that  iodo- 
thyrin  represents  in  some  measure  the  baser  ore,  which 
worked  in  the  fires  of  experience,  is  seen  and  known  in 
that  gift  of  the  gods  which  we  call  genius  ?  What  is  there 
in  the  history  of  science  to  make  us  doubt  that  some  day 

i68 


THE  THYROID  AND  HYPERTHYROIDISM 

we  will  be  able  to  read  backward  the  broader  history  of 
the  world,  finding  in  the  correlation  of  physiological  prin- 
ciples the  gall  of  Napoleon's  ambition  and  the  iron  of 
Caesar's  hand? 

Less  than  a  generation  ago,  Billroth,  Reverdin,  Miku- 
licz and  Kochcr,  blazing  the  trail  for  those  who  were  to 
come  after  them,  had  one  out  of  every  four  patients 
operated  on  for  goitre  develop  tetany.  A  description  of 
the  symptoms  given  by  one  of  the  old  authorities  reads 
as  follows : 

''Some  days  after  thyroidectomy,  ordinarily  on  the  third 
or  sixth  day,  sometimes  a  little  earlier  or  later,  the  pa- 
tient was  seized  with  convulsions  of  the  extrcmeties,  more 
often  the  superior,  which  were  sometimes  preceded  by 
tingling  in  the  fingers  or  twitching  of  the  muscles.  Usu- 
ally chronic  contractions  appeared ;  the  hands  closed  with 
such  violence  that  the  nails  often  penetrated  the  skin.  The 
limbs  were  sometimes  contracted  so  that  it  seemed  that 
they  were  going  to  break;  even  the  diaphragm  was  at 
times  involved." 

It  is  now  well  Iknown  that  tetany  is  not  due  to  removal 
of  the  thyroid  but  of  the  parathyroid  glands.  Mayo 
states  that  the  danger  of  tetany  in  thyroidectomy  under  a 
proper  technique  is  no  greater  than  that  of  pulmonary 
eml)olism  following  abdominal  surgery.  Thyroidectomy 
alone  docs  not  produce  tetany ;  removal  of  the  parathy- 
roids alone  does  cause  it.  The  symptoms  of  tetany  are 
not  relieved  by  giving  thyroid  extract ;  on  the  other  hand 
parathyroid  feeding  does  control  them.  Permanent  cure 
may  be  affected  by  transplanting  parathyroid  glands,  but 
a  successful  graft  cannot  be  made  unless  there  be  a  para- 
thyroid poverty. 

169 


THE  THYROID  AND  HYPERTHYROIDISM 

The  parathyroid  glands  have  been  studied  in  the  cat, 
dog,  monkey,  guinea-pig,  rabbit,  rat,  horse,  sheep,  goat, 
ox,  birds  and  man.  Forsyth  alone  examined  forty-two 
species  of  mammals  and  thirty-five  species  of  birds.  In 
man  they  are  normally  four  in  number,  small,  flat,  soft, 
yellowish-brown  bodies,  lying  along  the  posterior  margin 
of  the  thyroid.  McCallum  states  that  their  arrangement 
is  so  inconstant  that  a  composite  picture  of  many  dissec- 
tions shows  them  occupying  every  point  in  a  band  from 
top  to  bottom  of  the  thyroid.  Enlargements  of  the  thy- 
roid displace  them  out  of  all  recognition  in  operation. 

Chemically  no  predominating  feature  is  found,  such  as 
the  iodine  of  the  thyroid  gland.  Berkeley  and  Beebe, 
however,  obtained  a  nucleo-proteid  and  a  globulin.  The 
globulin  is  of  no  value  in  relieving  tetany.  But  according 
to  these  observers,  the  nucleo-proteid  will  relieve  tetany, 
when  given  by  mouth,  subcutaneously  or  intraperi- 
toneally. 

Before  the  role  of  the  parathyroids  in  tetany  was 
known,  acute  observers  had  recognized  the  low  calcium 
content  of  the  body  in  tetany  and  the  efficacy  of  these 
salts  in  the  control  of  the  condition.  Only  recently 
McCallum  and  Voegtlin  were  able  to  line  the  metabolic 
perversion  with  its  anatomical  origin. 

In  contrast  with  the  dramatic  phenomena  following 
sudden  loss  of  the  parathyroids,  their  slow  destruction 
brings  on  gradual  nutritional  disturbances.  These  may 
terminate  in  death  without  symptoms  of  tetany,  and  this 
phase  of  parathyroid  deficiency  must  be  given  due  consid- 
eration in  the  physiology  of  these  glands. 

Much  promising  work  is  now  being  done  to  determine 
the  relation  of  the  thyroid  gland  with  other  organs,  es- 

170 


THE  THYROID  AND  HYPERTHYROIDISM 

pecially  with  other  ductless  glands.  The  association  be- 
tween the  thyroid  and  the  sexual  organs,  the  pituitary 
body,  the  ardrenals,  the  thymus,  the  pancreas,  and  the 
parathyroids  is  substantiated  by  numerous  facts. 

The  relation  of  the  thyroid  to  the  sexual  function  is 
shown  by  its  congestion  following  coitus,  at  puberty  and 
the  menopause,  in  menstruation,  pregnancy  and  lactation. 
The  thyroid  tends  to  atrophy  with  the  decline  of  sexual 
power ;  and  the  cretin  is  marked  by  sexual  blight. 

The  pituitary  body  seems  to  be  in  close  alliance  with 
the  thyroid.  In  hypothyroidism  it  undergoes  hyper- 
trophy, apparently  compensatory;  while  in  acromegaly 
the  thyroid  is  usually  enlarged. 

The  adrenals  are  stimulated  by  the  thyroid.  In  Addi- 
son's disease  the  thyroid  is  frequently  atrophied,  though  it 
may  be  enlarged. 

The  thymus  gland  undergoes  hypertrophy  so  frequently 
in  exophthalmic  goitre  that  it  is  regarded  by  some  as  a 
part  of  the  essential  pathology. 

The  pancreas  is  inhibited  by  the  thyroid.  In  hyperthy- 
roidism degenerative  changes  are  frequently  seen  in  it, 
and  often  sugar  appears  in  the  urine.  On  the  other  hand, 
primary  pancreatic  insufficiency  is  at  times  followed  by 
marked  alterations  in  the  thyroid. 

Such  a  collection  of  facts,  inperfectly  linked  and  but 
poorly  understood,  is  more  suggestive  than  practical.  But 
it  is  prophetic  of  a  better  understanding  of  the  subject. 

At  this  time  we  are  not  able  to  say  how  the  ductless 
glands  are  controlled.  Though  they  respond  to  nervous 
influences,  the  functional  results  seen  in  grafts  cut  off 
from  all  demonstrable  nervous  connection  would  tend  to 
show  that  they  react  to  chemical  stimuli  contained  in  the 

171 


THE  THYROID  AND  HYPERTHYROIDISM 

blood,  known  as  hormones.  The  word  "hormone"  is  de- 
rived from  a  Greek  verb  meaning  to  awake  or  excite. 
Their  composition  is  largely  unknown.  They  act  by  sti- 
mulating organs  to  activity  and  are  not  nutritive  material 
to  body  cells.  A  very  small  quantity,  therefore,  is  suffi- 
cient for  the  exercise  of  their  function.  The  evidence 
seems  to  indicate  that  the  correlation  of  the  organs  of  in- 
ternal secretion  is  accomplished  through  their  medium. 
Responsive  to  the  call  of  these  quick  messengers,  the  in- 
ternal secretions  are  seen  in  a  silent  but  ceaseless  con- 
cert of  action.  It  is  probable  that  the  ductless  glands  are 
grouped  about  the  thyroid  as  the  director  of  the  phy- 
siological synergy.  It  brings  to  mind  the  words  of  Goethe 
in  his  tribute  to  Nature:  "She  is  the  unique  artificer, 
from  the  simplest  substances  to  the  greatest  contrasts, 
without  appearance  of  exertion  to  the  greatest  perfection; 
to  the  most  accurate  precision,  ever  suffused  with  some- 
what of  delicacy." 

The  histological  unit  of  the  thyroid  is  a  closed  follicle 
lined  with  a  single  layer  of  columnar  epithelium,  elaborat- 
ing a  secretion.  It  is  surrounded  by  lymph  channels  and 
blood-vessels  lying  in  a  connective  tissue  septum  derived 
from  the  capsule  of  the  gland.  Some  of  the  follicles 
have  a  lumen,  others  have  none.  Those  with  a  lumen 
are  filled  with  colloid  material.  The  difference  in  histolo- 
gical structure  of  a  normal  thyroid  and  the  thyroid  of  ex- 
ophthalmic goitre  is  about  the  same  as  the  difference  ob- 
served in  the  resting  and  the  lactating  breast.  The  change 
is  best  represented  by  the  term  "hypertrophic  parenchy- 
matous thyroid."  There  is  an  increase  in  the  number  of 
active  cells  in  the  follicles  or  increase  in  the  number  of 
follicles,  or  both.     For  symptoms  of  hyperthyroidism  to 

172 


THE  THYROID  AND  HYPERTHYROIDISM 

arise,  this  increase  must  be  sufficiently  general  to  out- 
weigh any  retrogressive  changes  that  may  be  going  on 
in  other  parts  of  the  gland.  There  must  also  be  ab- 
sorption of  the  secretion  at  a  rate  corresponding  to  the 
hyperplasia.  Otherwise  there  follows  retention  of  se- 
cretion, enlargement  of  the  gland,  and  development  of 
colloid  goitre,  with  a  subsidence  of  symptoms.  Thus 
it  is  seen  that  exophthalmic  and  simple  goitre  are  not 
separate  entities,  but  stages  of  one  process.  Wilson  says 
that  a  large  percentage  of  cases  of  simple  goitre  will  re- 
veal a  history  of  definite  signs  of  hyperthyroidism  if  in- 
quired into,  and  that  every  case  of  exophthalmic  goitre 
is  hypothetically  destined,  in  order  of  pathological  de- 
generation, to  become  a  case  of  simple  goitre.  Having 
reached  the  colloid  stage,  one  of  the  three  possibilities 
may  occur:  either  the  condition  may  persist  as  simple 
goitre,  or  active  hyperplasia  and  absorption  may  again 
arise  with  return  of  exophthalmic  symptoms ;  or  atrophic 
and  degenerative  changes  may  occur  resulting  in  myxe- 
dema. In  many  cases  of  untreated  hyperplastic  thyroid, 
secretion  ceases  before  retention  has  occurred.  These 
cases  show  clinically  either  a  return  to  normal  or  shade 
into  myxedema  with  atrophy  of  the  gland. 

Seen  in  proper  perspective  then,  changes  undergone  by 
the  thyroid  represent  a  series  at  first  progressive,  later 
'degressive,  but  never  assuredly  resting.  So  closely  do  the 
symptoms  follow  the  changes  described  that  the  history 
of  the  patient  can  be  written  by  the  pathologist  in  more 
than  80  per  cent  of  cases. 

Wilson  summarizes  the  pathology  about  as  follows : 
Very  early  acute  cases  show  hyperemia  and  cellular 
hyperplasia,  at  least  in  much  of  the  gland.    The  recently 

173 


THE  THYROID  AND  HYPERTHYROIDISM 

developed  very  mild,  or  moderately  mild,  cases  of  long 
standing  almost  always  show  some  total  parenchyma  in- 
crease, but  apparently  not  greatly  increased  functionating 
power.  Later  acute,  moderate,  severe  and  very  severe 
cases  show  greater  parenchyma  increase,  and  in  many 
cases,  greater  absorbable  secretion.  Cases  which  clini- 
cally are  showing  any  remission  of  toxic  symptoms,  show 
somewhere  within  the  gland  more  or  less  evidence  of  de- 
creased function.  Patients  who  have  recovered  from 
their  toxic  symptoms  and  are  now  sufifering  from  long, 
previously  acquired  heart  or  nerve  lesions  show  degenera- 
tive changes  and  large  quantities  of  colloid  that  is  probab- 
ly not  absorbable. 

Outside  of  the  thyroid  gland  itself,  other  tissue  changes 
should  be  regarded  as  secondary.  Any  attempt  to  in- 
clude as  primary,  functional  and  degenerative  changes  in 
the  nervous,  vascular  and  sympathetic  systems  will  lead 
only  to  confusion. 

Goitre  was  at  one  time  thought  to  be  a  disease  more  or 
less  limited  to  mountainous  countries.  It  is  now  known 
to  be  widely  disseminated.  Goitrous  districts  were 
thought  to  be  peculiarly  free  from  exophthalmic  goitre. 
This  idea  also  had  to  be  abandoned.  There  have  always 
been  many  cases  of  goitre  in  our  Southern  States.  Only 
recently,  however,  have  patients  with  goitre  been  referred 
to  the  surgeon,  owing  to  the  fact  that  no  promise  of  re- 
lief was  offered  them,  and  they  remained  under  the  care 
of  their  family  physicians.  Now  that  the  results  of  sur- 
gery are  more  generally  known,  patients  are  coming  to 
the  hospital  in  such  numbers  as  to  add  a  new  specialty  to 
operative  work. 

Hyperthyroidism  is  seen  most  often  in  the  third  de- 

174 


THE  THYROID  AND  HYPERTHYROIDISM 

cade  of  life.  It  is  comparatively  rare  at  either  extreme, 
though  Mayo  has  performed  thyroidectomy  for  its  cure 
in  a  child  of  seven.  Females  are  more  liable  than  males. 
According  to  Kocher,  the  disease  is  less  common  in  the 
laboring  class. 

Through  all  the  range  of  disease,  physiology  and  etiol- 
ogy are  inseparably  interwoven  and  in  exophthalmic 
goitre  the  cause  must  remain  more  or  less  obscure  until 
we  reach  a  better  understanding  of  the  function.  Just  as 
the  whole  truth  is  probably  not  embodied  in  any  one  of 
the  present  theories  as  to  function,  so  it  is  likely  that  the 
cause  is  a  complex  one.  The  water  and  the  soil,  social 
circumstances  and  racial  development  may  each  contri- 
bute a  factor. 

Beebe  distinguishes  the  following  groups  according  to 
etiology- :  First,  those  following  infectious  diseases ;  sec- 
ond, those  associated  with  pregnancy  or  disturbed  men- 
strual function ;  third,  those  arising  in  the  course  of  sim- 
ple goitre ;  fourth,  those  following  a  period  of  physical  or 
mental  overwork,  and  fifth,  those  due  to  severe  emotional 
disturbance  or  nervous  shock  of  some  kind. 

McCarty  assumes  that  the  thyroid  has  retrogressed. 
The  thyro-glossal  duct  formerly  opened  into  the  alimen- 
tary canal,  and  the  thyroid  may  at  one  time  have  had 
a  more  extensive  function  than  at  present.  He  regards 
hyperplasia  and  hyperthyroidism  as  a  reversion  of  the 
gland  to  its  former  type,  though  no  attempt  is  made  to 
point  out  the  stimulus  to  reversion.  Analogous  processes 
are  seen  in  supernumerary  mammary  glands. 

Crile  has  pointed  out  that  the  thyroid  plays  a  leading 
role  in  stimulating  the  emotions.  This  is  shown  by  their 
increase  upon  feeding  an  extract  of  the  gland,  and  by 

1/5 


THE  THYROID  AND  HYPERTHYROIDISM 

dimunution  on  removal  of  part  of  the  hyperplastic  thy- 
roid. The  symptoms  of  exophthalmic  goitre  closely  re- 
semble those  of  fear.  They  have  in  common  increased 
heart-beat,  rapid  respiration,  rise  in  temperature,  muscu- 
lar tremor,  protruding  eyes  and  loss  of  weight.  Crile 
believes  that  in  exophthalmic  goitre  there  is  a  reciprocal 
relation  between  the  brain  and  the  thyroid  gland.  The 
nerve  supply  of  the  gland  enters  along  the  walls  of  the 
blood  vessels  and  maintains  the  connection  between  the 
gland  and  the  brain.  According  to  Crile's  theory  ligation 
is  effective  through  breaking  this  nerve  connection. 

A  clear  conception  of  hyperthyroidism  as  a  form  of 
toxicosis  will  explain  all  the  more  important  symptoms. 
Recalling  the  tendency  of  any  toxemia  to  produce  in  time 
degenerative  changes  in  various  organs,  a  wide  range  of 
late  and  secondary  characteristics  are  readily  understood. 
When  the  enlargement  of  the  gland  is  present,  there  may 
be  introduced  another  factor,  namely,  pressure  upon  the 
neighboring  structures.  This  may  occur  even  though  uo 
external  enlargement  is  apparent. 

Tachycardia  is  probably  the  earliest,  most  constant  and 
most  reliable  of  any  single  symptom  or  sign.  The  pulse 
varies  from  90  to  120,  but  may  reach  a  much  higher  rate. 
It  is  usually  over  100.  It  is  the  best  index  to  the  severity 
of  the  disease,  and  the  best  criterion  of  improvement  or 
failure  under  any  plan  of  treatment.  The  patient  may 
or  may  not  be  aware  of  the  abnormal  heart  action ;  usual- 
ly, however,  he  is  conscious  of  it.  Murmurs,  both  cardiac 
and  vascular,  are  frequently  heard,  but  endocarditic 
changes  are  not  themselves  a  component  part  of  the  thy- 
roid heart.     Examination  of   the  blood   reveals  only  a 

176 


THE  THYROID  AND  HYPERTHYROIDISM 

relative  lymphocytosis,  not  peculiar  to  hyperthyroidism. 
Blood  pressure  is  an  unreliable  sign. 

Exophthalmos  is  a  comparatively  late  symptom.  It  is 
less  constant  than  the  rapid  pulse.  It  occurs  in  about 
three-fourths  of  all  cases.  Numerous  explanations  have 
been  advanced  for  the  development  of  this  symptom.  It 
is  not  unlikely  that  the  true  cause  has  been  located  in  the 
recent  demonstration  by  Landstroem  of  another  muscle 
in  the  orbital  space.  This  investigator  has  described  a 
cylindrical  band  of  plain  muscle  arising  from  the  septum 
of  the  orbit,  inserted  into  the  superior  aspect  of  the  bulb 
just  posterior  to  the  equator.  Stimulation  of  this  muscle 
through  the  sympathetic  system  would  cause  a  widening 
of  the  lid  slit  (Stellwag's  sign).  As  a  consequence  there 
arises  incoordination  of  the  movements  of  the  lid  and  ball 
(Von  Graefe's  sign).  A  spastic  condition  of  this  muscle 
would  also  tend  to  overcome  the  normal  tone  of  the  rectus 
internus  and  thus  upset  the  mechanism  of  convergence 
(Moebius'  sign).  Corneal  anesthesia,  inflammation  and 
nystagmus  are  all  seen  at  times,  and  are  the  results  of  the 
foregoing  changes  in  the  eye.  Thus,  if  Landstroems 
muscle,  stimulated  by  the  sympathetic,  proves  to  be  the 
cause  of  this  series  of  phenomena,  they  are  associated  di- 
rectly with  the  toxicosis  underlying  sympathetic  stimula- 
tion. 

Goitre  or  enlargement  of  the  thyroid  gland  occurs  in 
about  80  per  cent  of  cases.  The  size  of  the  enlargement 
bears  no  relation  to  the  severity  of  the  toxic  symptoms. 
Tachycardia  and  nervousness,  on  the  contrary,  are  more 
liable  to  be  exaggerated  in  association  with  the  smaller 
tumors.  Owing  to  the  fibrous  attachments  to  the  trachea 
and  esophagous,  the  tumor  rises  and  falls  with  degluti- 
tion.   Mobility  is  greater  in  the  lateral  than  in  the  vertical 

177 


THE  THYROID  AND  HYPERTHYROIDISM 

direction.  Both  lobes  are  enlarged  but  the  right  is  usu- 
ally larger  than  the  left.  Pressure  on  the  trachea  may 
cause  dyspnoea  and  pressure  on  the  blood  vessels  may 
produce  headache,  vertigo,  engorgement  of  the  jugular 
and  edema  of  the  face.  As  a  result  of  either  toxicosis  or 
pressure,  nearly  every  patient  will  describe  sensations 
about  the  head,  varying  in  graphic  force  with  his  powers 
of  expression.  Pressure  on  the  recurrent  nerve  may 
cause  paralysis  of  the  laryngeal  muscles.  The  resultant 
hoarseness  is  rarely  permanent,  as  only  one  nerve  is  af- 
fected, and  the  laryngeal  muscles  in  time  accommodate 
themselves  to  compensate  for  the  injury.  Dysphagia  is  not 
common,  nor  is  pain  often  a  symptom  of  goitre,  coming 
late  even  in  malignant  degeneration. 

Tremor,  especially  of  the  fingers,  is  almost  as  charac- 
teristic, if  not  quite  as  constant,  as  any  of  the  foregoing 
symptoms.  It  may  vary  considerably  in  degree.  There 
is  a  fine  rhythmic  movement  with  from  eight  to  ten  vibra- 
tions to  the  second. 

"Nervousness"  is  an  early  and  frequent  complaint.  Too 
often  it  is  passed  by  with  pity  or  contempt.  Irritability, 
excitability,  restlessness  and  insomnia,  parasthesia,  verti- 
go and  faintness,  mental  fatigue  and  loss  of  memory,  de- 
pression, apprehension  and  morbid  fears,  are  common 
mental  states.  Fortunately  less  common  are  hallucina- 
tions, confusion  of  ideas,  delirum  and  suicidal  or  homi- 
cidal mania. 

Alimentary  disturbances  are  common,  due  to  function- 
al and  degenerative  changes  the  result  of  toxemia.  The 
occurrence  in  spite  of  a  good  appetite  of  rapid  emacia- 
tion is  as  peculiar  here  as  in  diabetes.  Abdominal  criscis 
may  occur  simulating  those  of  tabes.    A  diarrhea  is  seen 

178 


THE  THYROID  AND  HYPERTHYROIDISM 

in  about  one-third  of  the  cases,  due  to  subacidity  of  the 
gastric  contents. 

Body  weight  may  be  lost  from  ten  to  thirty  or  even 
sixty  pounds  in  a  short  while.  It  may  be  regained  almost 
as  rapidly.  The  skin  is  warm,  moist  and  relaxed.  The 
patient  complains  of  a  sensation  of  subjective  warmth. 
Sweating  is  profuse  to  a  characteristic  degree.  Vaso- 
motor instability  is  shown  in  mottling  of  the  skin.  Pig- 
mentation of  the  skin  is  common.  Fever  is  present  in 
the  severe  acute  cases,  and,  according  to  Stern,  is  even 
more  common  in  the  mild  types. 

The  pathological  changes  in  the  thyroid  gland  and  the 
clinical  course  of  exophthalmic  goitre  closely  parallel  each 
other.  Rogers  describes  the  course  of  the  disease  in  four 
stages,  as  follows : 

First — In  the  incipent  stage,  the  patient  may  notice 
fatigue  too  readily  induced.  Loss  of  appetite,  insomnia, 
irritability  and  slight  dyspnoea  may  ensue.  If  tachycar- 
dia appears  the  disease  is  progressing.  Throughout  this 
early  stage  are  seen  symptoms  of  a  vague  but  distinct 
coupling  of  the  emotions  and  the  central  nervous  system, 
the  heart  and  vaso-motor  apparatus,  the  digestive  and 
muscular  systems.  All  alike  seem  to  feel  the  whip  of 
insidious  toxins  stinging  their  several  systems  into  fev- 
erish activity,  sapping  stamina  and  disorganizing  order- 
ly co-operation.  The  picture  is  strikingly  suggestive  of 
the  intoxication  of  a  chronic  infection  such  as  tuberculo- 
sis, or  a  more  dangerous  pitfall  yet,  these  vague  com- 
plaints might  be  classed  as  neurasthenic. 

If  the  disease  remains  untreated  it  usually  progresses  to 
the  second  stage  of  distinct  hyperthyroidism.  Plummer 
states  that  on  an  average  patients  appear  at  the  Mayo 

179 


THE  THYROID  AND  HYPERTHYROIDISM 

clinic  for  treatment  three  years  after  the  first  evidence 
of  intoxication.  This  stage  is  apt  to  show  one,  two,  or 
all  of  the  classical  triad :  tachycardia,  exophthalmos  and 
goitre,  and  it  is  at  this  time  that  the  picture  is  most 
typical. 

The  third  stage  is  that  of  chronic  exophthalmic  goitre. 
When  the  disease  has  lasted  a  long  time,  and  particularly 
after  treatment  has  been  applied,  the  gland  may  harden 
and  the  vascular  phenomena  diminish.  The  symptoms 
can  be  demonstrated  at  once,  however,  by  any  excitment. 
Remissions  of  greater  or  less  duration  are  quite  charac- 
teristic, and  there  is  a  tendency  to  relapse  or  exacerba- 
tions. It  is  in  this  chronic  stage  that  both  exophthalmos 
and  goitre  are  likely  to  be  pronounced.  The  various  psy- 
choses are  then  more  apt  to  appear. 

Coincident  with  the  atrophic  and  degenerative  changes 
in  the  thyroid,  the  typical  case  progresses  to  the  final  or 
myxedematous  stage.  With  the  goitre  of  the  same  size 
or  enlarging,  the  weakness  is  progressive,  the  skin  be- 
comes pale  and  shows  increased  puflfiness  about  the  eyes 
and  face,  with  dense  edema  of  the  lower  extremeties, 
mental  torpor,  slow  pulse  and  anemia. 

The  diagnosis  of  exophthalmic  goitre  is  often  difficult 
in  the  early  stages,  but  this  is  the  period  the  disease  should 
be  recognized,  as  treatment  is  then  much  more  efficient 
than  later.  The  name  of  the  disease  is  misleading,  as  fre- 
quently the  eyes  are  not  prominent  and  the  thyroid  is  not 
appreciably  enlarged.  Tachycardia  is  the  most  constant 
symptom,  and  when  it  persists  without  obvious  cause, 
such  as  hysteria,  cardiac  disease,  tobacco,  whisky  or  drug 
addiction,  hyperthyroidism  should  be  suspected ;  and  a 
postive  diagnosis  is  justified  if  either  goitre  or  exophthal- 

j8o 


THE  THYROID  AND  HYPERTHYROIDISM 

mos  is  found  to  co-exist.  The  presence  of  tremor,  sweat- 
ing, muscular  weakness,  nervous  excitability,  digestive 
disturbances,  emaciation  and  characteristic  blood  changes 
leave  no  question  as  to  the  nature  of  the  disease.  Not 
looking  is  a  more  frequent  source  of  error  in  the  diagnosis 
than  not  knowing. 

The  symptoms  of  hyperthyroidism  are  increased  by 
excitement  or  exertion.  The  tendency  to  remissions  or 
exacerbations  must  be  borne  in  mind.  At  one  observa- 
tion the  patient  may  have  an  enlarged,  pulsating  goitre, 
prominent  eyes  and  rapid  pulse ;  and  at  another  the  gland 
may  be  smaller,  the  eyes  nearly  normal  and  the  pulse  com- 
paratively slow  and  regular.  This  fact  is  believed  to  be 
due  to  thyroid  secretion  accumulating  in  the  gland  until, 
from  some  apparent  or  unknown  cause,  it  suddenly 
throws  its  contents  into  the  circulation. 

The  differential  diagnosis  of  hyperthyroidism  from  hys- 
teria is  sometimes  difficult.  In  both  diseases  the  patient 
often  dates  the  onset  from  some  mental  or  physical  shock. 
In  both  there  are  tachycardia,  nervousness  and  muscular 
weakness,  and  in  both  there  is  often  some  difficulty  in 
swallowing,  caused  by  the  goitre  in  the  one  case  and  the 
globus  hysterica  in  the  other. 

Early  tuberculosis  may  closely  simulate  hyperthyroid- 
ism. Tachycardia,  slight  fever,  nervousness,  emaciation 
and  weakness  are  common  to  both.  In  incipient  tuber- 
culosis the  patient  is  usually  in  good  spirits,  while  thyroid 
intoxication,  as  a  rule,  causes  despondency  Physicnl  ex- 
amine tjon  of  the  chest  and  X-ray  piceure  should  serve  to 
distinguish  the  two  in  most  cases.  The  therapeutic  test 
of  the  administration  of   thyroid   extract  over  a  short 

i8i 


THE  THYROID  AND  HYPERTHYROIDISM 

period  may  be  useful,  for  if  hyperthroidism  exists  the 
symptoms  are  made  worse. 

Despite  the  low  mortality  as  now  reported  in  the  hands 
of  numerous  surgeons,  a  patient  should  not  be  treated 
surgically  until  medical  measures  have  been  tried  and 
proved  inefficient,  as  from  one-fourth  to  one-half  of  all 
patients  suffering  with  exophthalmic  goitre  will  get  well 
without  operation.  Whether  their  recovery  is  due  to  the 
remedies  prescribed  by  the  physician  or  the  inherent  tend- 
ency of  the  system  to  overcome  an  abnormality,  is  not  a 
material  question.  The  practical  fact  is  that  these  pa- 
tients should  be  treated  along  accepted  lines  and  given 
reasonable  time  to  see  what  nature  will  do  for  them,  be- 
fore they  are  subjected  to  surgical  risk.  If,  however, 
they  fail  to  improve  or  their  symptoms  get  worse,  then 
an  operation  should  be  advised  before  complications  de- 
velop or  incurable  structural  changes  take  place  in  the 
heart,  eyes  and  other  organs.  In  other  words,  the  sur- 
geon should  not  operate  on  a  case  too  soon,  and  the  phy- 
sician should  not  treat  a  case  too  long. 

The  medical  treatment  of  hyperthyroidism  consists  pri- 
marily in  rest.  If  possible  the  patient  should  be  placed 
in  a  hospital  for  a  time  and  confined  to  bed.  An  ice  bag 
over  the  heart  is  often  of  temporary  benefit.  Various 
drugs  have  been  advocated  by  different  authorities,  but  no 
two  seem  able  to  get  the  same  results  in  either  experimen- 
tal or  clinical  work.  All  agree  that  iodine  and  thyroid 
extract  should  not  be  employed.  As  myxedema  and  ex- 
ophthalmic goitre  are  the  antithesis  one  of  the  other,  one 
of  the  earliest  treatments  consisted  in  injecting  the  serum 
of  the  blood  of  a  patient  suffering  with  myxedema  into 
the  circulation  of  the  victim  of  hyperthyroidism.     Some 

182 


THE  THYROID  AND  HYPERTHYROIDISM 

temporary  good  resulted.  The  next  effort  in  this  direc- 
tion was  the  use  of  a  serum  called  antithyroidin,  obtained 
from  the  blood  of  a  thyroidectomized  sheep.  Theoretical- 
ly, the  blood  of  an  animal  whose  thyroid  had  been  re- 
moved should  contain  the  toxin  which  would  combine 
with  and  neutralize  thyroglobulin ;  but  the  remedy  failed 
to  prove  of  therapeutic  value.  Several  years  ago  a  cyto- 
lytic and  antitoxic  serum  was  introduced  by  Rogers  and 
Beebe.  The  reputation  of  the  originators  and  the  good 
results  reported  by  those  who  first  used  it  encouraged  the 
profession  to  hope  that  a  specific  for  the  disease  had  at 
last  been  found.  This  expectation  has  not  been  realized. 
In  a  recent  personal  communication,  Dr.  Rogers  states 
that  he  regards  the  serum  as  very  valuable  in  the  treat- 
ment of  toxemic  patients,  but  it  is  merely  an  adjuvant  for 
helping  out  a  small  number  of  cases.  He  regards  as  the 
rational  treatment  of  hyperthyroidal  disturbances  the  liga- 
tion of  arteries  or  the  extirpation  of  limited  foci  of  dis- 
ease, which,  by  pressure  upon  the  sound  parts  of  the 
gland,  may  interfere  with  nutrition  of  the  organ. 

While  as  yet  serum  therapy  has  been  unsuccessful,  the 
work  of  men  like  Rogers  and  Beebe  will  eventually  tri- 
umph. The  day  will  come  when  some  specific  of  ani- 
mal origin  will  be  discovered  that  will  act  as  beneficially 
in  exophthalmic  goitre  as  thyroid  extract  does  in  myxe- 
dema. 

Electricity,  that  mysterious  agent  which  has  promised 
so  much  and  accomplished  so  little  in  the  treatment  of  va- 
rious diseases,  has,  of  course,  been  tried  for  hyperthy- 
riodism.  Faradism  has  a  few  advocates.  Galvanism,  es- 
pecially in  the  form  of  electrolysis  and  cataphoresis,  has 
been  extensively  employed.     The  X-ray  seemed  at  one 

183 


THE  THYROID  AND  HYPERTHYROIDISM 

time  to  have  established  a  place  for  itself.  Beck  reports 
good  results  in  the  treatment  of  small  goitres.  Mayo  still 
uses  it  in  certain  cases  as  preliminary  to  operation,  claim- 
ing it  produces  sclerosis  of  the  gland.  Von  Eiselsberg, 
Deaver  and  others  after  extensive  trial,  say  it  has  pos- 
tively  no  beneficial  effect. 

Injections  into  the  gland  of  alcohol,  iodine  carbolic  acid 
and  iodoform  emulsion  have  been  tried  and  abandoned. 
Abbey  has  used  radium  and  reports  £:ood  results.  Porter 
has  published  a  number  of  cases  markedly  improved  by 
the  injection  of  boiling  water,  the  technique  being  the 
same  as  that  employed  by  Wyeth  in  the  treatment  of  an- 
gioma. This  treatment  causes  a  coagulation  of  the  blood 
and  acts  on  the  principle  of  a  ligation  operation.  There 
would  seem  to  be  little  to  commend  it. 

Statistics  showing  the  results  of  non-operative  treat- 
ment are  meager.  White  followed  up  the  histories  of 
102  cases  admitted  to  Guy's  Hospital  between  1888  and 
1907.  In  White's  series  60  per  cent  recovered,  20  per 
cent  were  improved,  5  per  cent  had  not  done  well,  and 
15  per  cent  had  died. 

The  surgical  treatment  of  hyperthyroidism  owes  its 
conception  to  the  accidental  observation  that  patients 
operated  on  to  relieve  them  of  the  mechanical  or  pressure 
symptoms  of  goitre,  were  also  cured  of  their  toxic  symp- 
toms, such  as  tachycardia,  tremor,  nervous  irritability, 
muscular  weakness  and  loss  of  weight. 

The  development  of  the  surgical  treatment  is  largely 
due  to  the  work  of  Theodor  Kocher  of  Berne,  Switzer- 
land. A  generation  ago  the  operation  of  thyroidectomy 
was  considered  one  of  the  most  dangerous  in  surgery. 
Kocher's  mortality  in  his  first  seventy  cases  of  simple 

184 


THE  THYROID  AND  HYPERTHYROIDISM 

goitre  was  40  per  cent;  Charles  H.  Mayo's  mortality  in 
his  first  sixteen  cases  of  exophthalmic  goitre  was  25  per 
cent.  It  is  no  wonder  that  at  one  time  the  operation  was 
regarded  by  the  majority  of  the  surgeons  as  unwarranted, 
and  it  is  not  surprising  that  there  are  still  today,  some 
among  the  older  practitioners  who  hesitate  to  advise  a 
patient  with  goitre  to  seek  operative  relief  except  as  a 
last  resort.  Times  have  changed,  however,  and  the  op- 
eration has  been  rendered  comparatively  simple  and  safe 
in  experienced  hands.  Kocher  with  a  courage  that  seemed 
man^elous  to  the  present  generation  of  surgeons,  per- 
sisted in  his  work  until  he  finally  established  a  technique 
that  has  reduced  the  mortality  in  his  last  one  thousand 
cases  of  goitre  to  three-tenths  of  one  per  cent.  This  was 
accomplished  by : 

T.  Early  operations  on  more  favorable  cases. 

2.  Improved  aseptic  methods  to  prevent  infection. 

3.  Better  methods  of  anesthesia. 

4.  An  exposure  which  gave  ability  to  control  hemor- 
rhage and  avoid  injury  to  certain  structures  of  the  neck. 

All  operations  have  for  their  object  the  diminution  of 
thyroid  secretion.  This  is  accomplished  in  one  or  two 
ways :  either  by  lessening  the  amount  of  the  blood  going 
to  the  gland  by  ligation  of  one  or  more  of  the  principal 
arteries,  or  by  reducing  the  amount  of  secreting  structure 
by  excision  of  part  of  the  gland.  Crile  thinks  in  both 
ligation  and  excision  the  benefit  results  not  only  from  les- 
sening the  blood  supply  and  diminishing  the  secreting 
structure,  but  also  from  cutting  oflf  the  nerve  supply. 

Ligations  are  indicated  in  very  mild  cases  where  this 
operation  may  be  all  that  is  necessary  to  effect  a  cure; 
and  in  verv  bad  cases  as  a  preliminary  to  a  more  radical 

185 


THE  THYROID  AND  HYPERTHYROIDISM 

operation  when  the  condition  of  the  patient  improves 
sufficiently  to  make  it  safe. 

The  operation  of  excision  usually  consists  in  the  re- 
moval of  one  lobe  and  the  isthmus.  The  difficult  and  im- 
portant question  that  confronts  the  surgeon  in  every  case 
is  how  much  thyroid  tissue  he  should  take  out.  If  he 
removes  too  little,  the  symptoms  of  hyperthyroidism  con- 
tinue ;  if  he  removes  too  much,  the  symptoms  of  hypo- 
thyroidism develop.  Rogers  has  impressed  the  fact  that 
operations  which  give  brilliant  immediate  results  are  of- 
ten followed  by  remote  difficulties  and  complications.  A 
compensatory  hyperthrophy  of  the  remaining  lobe  may 
develop  with  persistence  of  exophthalmic  goitre  symp- 
toms, or  degenerative  changes  may  take  place  in  the  tissue 
left,  with  the  development  of  myxedema.  Until  we  know 
more,  surgery  should  not  be  too  radical.  If  an  error  is 
made,  it  had  better  be  on  the  side  of  conservatism,  as  it 
is  easy  to  take  out  more,  but  impossible  to  put  back  any, 
of  the  tissue  which  has  such  an  important  effect  on  the 
physical  nutrition  and  nervous  equilibrium  of  the 
individual. 

Mayo  states  that  the  thyroid  gland  has  a  ''factor  of 
safety"  of  six;  in  other  words,  that  one-sixth  of  the 
gland  can  carry  on  its  work.  The  removal  of  one  lobe 
and  the  isthmus  means  the  excision  of  about  three-fifths 
of  the  gland,  and  this  is  the  common  practice  of  most 
surgeons. 

The  dangers  attending  the  operation  of  partial  thyriod- 
ectomy  were  formerly  discussed  under  numerous  heads. 
Infection,  hemorrhage  and  shock  have  been  so  minimized 
by  modern  methods  that  they  are  not  more  likely  to  oc- 
cur than  during  other  major  operations.     Injury  to  the 


THE  THYROID  AND  HYPERTHYROIDISM 

recurrent  larg}ngeal  nerve  can  be  avoided  by  care  in 
ligating  the  inferior  thyroid  artery,  and  is  an  accident 
less  frequent  than  cutting  the  ureter  in  hysterectomy.  Te- 
tany can  be  prevented  by  leaving  the  posterior  capsule  of 
the  gland,  thus  assuring  the  preservation  of  the  parathy- 
roids. Myxedema  can  be  guarded  against  by  leaving 
enough  active  thyroid  tissue  to  carry  on  the  function  of 
the  gland. 

The  danger  of  the  anesthetic  has  been  much  discussed. 
Kocher,  Tinker,  and  others  operate  almost  exclusively 
with  local  anesthesia,  and  attribute  their  low  mortality 
largely  to  its  use.  Mayo,  Ochsner  and  others  use  a  gen- 
eral anesthetic  and  get  just  as  good  results. 

The  one  and  only  special  danger  in  the  surgical  treat- 
ment of  exophthalmic  goitre  is  acute  hyperthyroidism. 
When  this  condition  develops  the  symptoms  come  on 
shortly  after  the  patient  is  removed  from  the  table,  and 
consist  in  rapid  pulse,  high  fever,  great  restlessness,  and 
often  wild  delirium.  Acute  hyperthyriodism  after  an 
operation  was  formerly  thought  to  be  due  to  squeezing 
the  gland  and  the  absorption  of  its  juices  by  the  raw 
surfaces  of  the  wound.  This  theory  has  been  discredited 
on  the  ground  that  the  thyroid  in  exophthalmic  goitre  has 
been  repeatedly  and  thoroughly  massaged  by  osteopaths 
without  producing  marked  increase  in  the  symptoms. 
Kocher  as  a  routine  measure  crushes  a  zone  of  the  gland 
with  a  heavy  forcep  prior  to  its  ligation  and  division, 
and  no  increase  of  hyperthyroidism  has  been  noted.  A 
number  of  surgeons  who  at  one  time  cauterized  the  wound 
or  painted  it  with  Harrington's  solution,  to  prevent  ab- 
sorption, have  now  abandoned  the  practice  because  it  did 
no  good. 

187 


THE  THYROID  AND  HYPERTHYROIDISM 

Crile  believes  that  acute  hyperthyroidism  after  an  op- 
eration is  due  to  excessive  secretion  of  the  gland  caused 
by  psychic  and  traumatic  stimuli.  The  psychic 
factor  is  excitement  and  fear.  This  may  be  independent 
of  mechanical  injury  to  the  thyroid  as  shown  by  the  fact 
that  the  symptoms  often  develop  in  susceptible  patients 
after  operations  on  other  parts  of  the  body.  The  method 
used  by  Crile  to  eliminate  this  factor  is  to  inspire  the  pa- 
tient with  confidence  and  keep  him  in  ignorance  of  the 
time  of  operation. 

The  traumatic  factor  consists  in  the  impulses  that  pass 
from  the  field  of  operation  to  the  central  nervous  system. 
Crile  claims  that  a  general  anesthetic  does  not  prevent  in- 
jurious impulses  reaching  the  brain  and  causing  exhaus- 
tion and  shock.  The  use  of  a  local  anesthetic,  however, 
temporarily  disconnects  the  part  being  operated  on  from 
the  brain.  He  therefore,  cocainizes  the  field  of  operation 
as  thoroughly  as  if  no  general  anesthetic  were  employed. 
With  these  two  precautions,  he  states,  ligation  or  excision 
may  be  done  in  desperate  cases  without  fear  of  acute  hy- 
perthyroidism. The  method  is  very  valuable  in  certain 
cases,  but  it  is  too  elaborate  and  time-consuming  to  be 
adopted  as  a  routine  practice  by  many  surgeons  in  all 
cases. 

When  a  patient  with  exophthalmic  goitre  comes  to  a 
surgeon,  the  case  ought  to  be  kept  under  observation  and 
carefully  studied  for  some  days  before  deciding  on  the 
character  of  the  operation  best  suited  to  the  individual, 
and  the  safest  time  to  perform  it.  Tinker  impresses  the 
fact  that  an  examination  of  a  patient  who  has  been  kept  at 
rest  for  some  days  may  give  an  erroneous  impression  of 
the  safety  of  the  operation.    On  the  other  hand,  a  patient 

i88 


THE  THYROID  AND  HYPERTHYROIDISM 

coming  from  a  distance,  fatigued  and  frightened,  may 
give  the  impression  of  a  worse  operative  risk  than  is 
really  the  case. 

Mayo  states  that  the  operation  for  exophthalmic  goitre 
is  not  one  of  emergency,  nor  is  it  to  be  called  life-saving 
in  extreme  cases,  and  it  should  not  be  undertaken  except 
at  a  proper  time.  He  calls  attention  to  the  exacerbations 
and  remissions  in  the  intensity  of  the  symptoms,  which 
he  attributes  to  the  accumulation  and  discharge  of  toxic 
substances  in  the  gland.  He  believes  that  if  the  patient  is 
carefully  watched,  these  periods  can  be  predicted,  and  the 
most  favorable  time  for  the  operation  is  not  when  the 
patient's  symptoms  are  at  the  best,  but  shortly  after  the 
gland  has  dumped  its  load  and  before  it  again  becomes 
laden  with  toxic  material. 

Some  cases  can  safely  be  operated  on  after  one  or  two 
day's  study;  others  require  weeks  of  rest  and  medical 
treatment  preliminary  to  the  operation.  Some  cases  re- 
quire ligation  of  one  or  more  arteries  before  it  is  safe 
to  excise  a  portion  of  the  gland ;  other  cases  should  have 
one  lobe  and  the  isthmus  removed  without  preliminary 
ligation.  Tinker  describes  a  desperate  case  Avhich  was 
saved  by  a  graduated  operation  divided  into  five  separate 
stages  at  intervals  varying  from  a  few  days  to  several 
weeks. 

Surgery  of  the  thyroid  is  still  in  its  developmental  stage. 
In  reading  the  literature  one  is  impressed  by  the  fact 
that  each  author,  at  one  time,  attributed  his  good  results 
to  some  special  feature  of  his  operation  which  he  has 
since  found  unnecessary  or  injurious  and  has  abandoned. 
Fads  are  fast  disappearing,  and  the  work  is  rapidly  ap- 

189 


THE  THYROID  AND  HYPERTHYROIDISM 

preaching  the  practice  of  basic  principles  underlying  es- 
tablished surgery. 

In  the  hands  of  men  like  Mayo,  Kocher,  Ochsner,  Crile, 
Tinker  and  others,  the  mortality  of  operations  for  hyper- 
thyroidism is  now  from  two  to  five  per  cent,  and  85  per 
cent  of  those  who  recover  may  be  said  to  be  symptoma- 
tic cures.  It  is  neither  honest  nor  expedient,  however,  to 
make  light  of  the  operation  or  to  belittle  its  difficulties 
and  dangers.  The  figures  quoted  are  from  the  statistics 
of  master  surgeons,  and  by  no  means  represent  the  results 
of  the  average  operator. 

After  a  successful  operation  for  hyperthyroidism,  the 
improvement  in  the  patient  is  immediate  and  marked.  In 
fact,  no  operation  in  surgery  produces  such  quick  and 
brilliant  results.  Tremor  disappears,  the  pulse  falls  to 
normal,  the  eyes  become  less  wild,  and  restlessness  and 
irritability  are  replaced  by  quiet  and  composure.  The 
wound,  as  a  rule,  heals  rapidly,  and  the  patient  is  able 
to  leave  the  hospital  in  from  ten  to  fourteen  days. 

Because  the  patient  is  well  from  the  operation,  and 
because  the  acute  symptoms  are  relieved,  is  not  ground 
for  immediate  return  to  the  ordinary  activities  of  Hfe. 
Crile  very  properly  states  that  it  requires  approximately 
the  same  time  to  recover  from  exophthalmic  goitre  as 
from  a  nervous  breakdown  from  other  causes.  A  suc- 
cessful operation  should  be  followed  by  an  adequate  rest 
cure. 


190 


The  Diagnosis  and  Treatment  of 
Hypothyroidism.* 

The  thyroid  gland  is  in  many  respects  the  most  won- 
derful organ  of  the  body.  Through  its  internal  secretion 
it  influences  the  physical  development  of  the  child,  and 
the  psychic  condition  and  mental  activity  of  the  adult. 
It  regulates  the  growth  of  bone,  the  formation  and  dis- 
tribution of  fat,  and  the  nutrition  of  the  skin,  teeth,  hair 
end  nails.  It  plays  an  important  part  in  menstruation 
and  parturition,  and  has  much  to  do  with  sexual  desire 
and  power.  It  influences  the  rate  of  heart  beat,  the  char- 
acter of  the  peripheral  circulation,  and  hence  markedly 
affects  the  general  blood  pressure.  It  presides  over  the 
nitrogenous  metabolism  of  the  body  and  in  other  known, 
and  perhaps  unsuspected  ways,  plays  an  important 
part  in  the  human  economy. 

Many  theories  have  been  advanced  to  explain  the  pro- 
tean action  of  thyroid  secretion,  but  at  this  time  it  is 
impossible  to  say  which  is  the  true  one.  Either  as  a  neu- 
tralizer  of  endogenous  toxins,  or  as  a  hormone  stimulat- 
ing other  organs  and  tissues  to  activity,  or  by  some  other 
obscure  but  potent  influence,  it  is  the  pace  maker  for  the 
body.  Thyroid  secretion  seems  to  act  as  the  gasoline  for 
the  human  automobile.  If  the  lever  controlling  its  supply 
is  advanced  then  the  engine  races,  the  gears  grind  and  the 
whole  machine  throbs  and  vibrates.     If  the  lever  is  re- 


*Read  before  the   North  Carolina  Medical   Society,  June   i8, 

191 


THE  DIAGNOSIS  AND  TREATMENT  OF 

tarded  then  the  engine  knocks,  the  pistons  hang,  and  the 
halting  machinery  momentarily  threatens  to  come  to  a 
standstill. 

If  thyroid  secretion  is  excessive  there  are  symptoms 
of  metabolic  riot.  Heat  production  and  gaseous  inter- 
change are  rapid.  The  body  tissues  are  stimulated  to  a 
course  of  wasting  dissipation.  There  are  seen  tremor, 
sweating,  tachycardia,  muscular  weakness,  loss  of  weight 
and  feverish  mental  activity. 

If  thyroid  secretion  is  deficient  the  metabolism  of  the 
body  is  depressed  and  heat  production  and  gaseous  in- 
terchange are  at  a  low  ebb.  In  the  young,  growth  is 
lessened  and  the  skeletal  system  is  dwarfed.  Connective 
tissue  cells  remain  myxomatous.  The  skin  is  dry  and 
thick  and  the  hair  is  coarse  and  shows  deficient  nourish- 
ment. The  nervous  system  halts  in  development  and 
mentality  does  not  rise  above  the  level  of  the  infant. 

My  interest  in  the  thyroid  gland  was  first  attracted  by 
the  cases  of  exopthalmic  goitre  that  came  to  me  for  sur- 
gical treatment.  The  symptoms  in  the  advanced  type  of 
this  disease  were  so  dramatic  and  the  results  of  opera- 
tions directed  to  reducing  the  supply  of  thyroid  secretion 
to  the  system  so  immediate  and  remarkable  that  I  was 
tremendously  impressed  with  the  important  role  the  thy- 
roid gland  played  in  the  physiology  of  the  human  or- 
ganism. 

The  study  of  hyperthyroidism  as  seen  in  exopthalmic 
goitre  naturally  led  me  to  the  study  of  hypothyroidism 
as  seen  in  myxedema,  and  the  increasing  number  of  cases 
coming  under  my  observation  where  the  symptoms  were 
demonstrated  to  be  due  to  excess  of  thyroid  activity  led 
me  to  wonder  if  there  were  not  an  equal  number  of 

192 


HYPOTHYROIDISM 


patients  who  suffered  from  symptoms  due  to  deficient 
thyroid  secretion. 

Any  diagnostician  will  of  course  recognize  at  once  a 
fully  developed  case  of  exopthalmic  goitre  with  its  star- 
ing eyes,  bulging  throat,  tachycardia,  tremor,  sweating, 
nervous  irritability  and  loss  of  weight,  or  a  marked  case 
of  infantile  myxedema  such  as  has  been  so  graphically 
described  by  Osier.  The  stunted  statue  and  squat  figure ; 
the  blubber  lips,  sunken  nose,  lolling  tongue  and  half 
closed  eyes,  the  expressionless  face,  thick  skin  and  coarse 
hair  make  a  picture  that  cannot  be  mistaken. 

But  there  are  other  cases  where  the  symptoms  due  to 
perverted  thyroid  secretion  are  not  so  clear  and  well 
defined,  and  cases  of  mild  hyperthyroidism  have  often 
been  treated  for  hysteria  or  neurasthenia,  and  cases  of 
mild  hypothyroidism  have  often  been  treated  for  anemia 
or  malaria. 

Surgeons  in  recent  years  have  learned  to  be  constantly 
on  the  watch  for  symptoms  of  hyperthyroidism  and  many 
cases  of  the  disease  are  diagnosticated  and  treated  in  the 
incipient  stage,  but  physicians  as  a  rule  have  not  yet  been 
trained  to  the  same  vigilance  in  the  detection  of  the  early 
symptoms  of  hypothyroidism,  a  condition  of  equal  fre- 
quency and  importance  and  one  much  more  easily  treated. 

From  observation  and  study  I  am  satisfied  there  are 
a  large  number  of  patients  who  suffer  from  thyroid  pov- 
erty and  who  drift  from  physician  to  physician  without 
the  cause  of  their  symptoms  being  suspected. 

A  proper  diagnosis  in  this  class  of  cases  must  be  based 
on  a  thorough  knowledge  of  the  physiological  action  of 
the  thyroid  gland  and  a  study  of  the  symptoms  that  follow 
its  perverted  function.    In  doubtful  cases  thyroid  extract 

193 


THE  DIAGNOSIS  AND  TREATMENT  OF 

may  be  given  in  small  doses  as  a  therapeutic  test,  and 
continued  if  it  does  good  and  discontinued  if  it  does 
harm. 

Thyroid  extract  should  never  be  given  in  cases  of 
heart  lesion,  albuminuria  or  glycosuria.  In  other  cases 
if  it  produces  dizziness,  intoxication  or  cardiac  disturb- 
ances it  need  not  be  discontinued  at  once  as  the  untoward 
symptoms  can  be  relieved  by  the  administration  of  Fow- 
ler's solution  of  arsenic.  The  dose  of  thyroid  extract 
should  be  a  small  one,  not  over  two  grains  three  times 
a  day  and  the  common  mistake  should  not  be  made  in 
acting  on  the  belief  that  if  a  little  is  good  more  will  be 
better.  A  small  dose  long  continued  is  safer  and  more 
efficient  than  a  large  dose  given  for  a  short  time.  It 
must  also  be  remembered  that  many  of  the  thyroid  prepa- 
rations on  the  market  are  absolutely  inert  and  the  phy- 
sician should  either  prescribe  a  standardized  tablet  made 
by  a  reliable  manufacturer  or  else  activate  the  tablet  of 
unknown  efficiency  by  combining  with  it  several  grains  of 
iodide  of   soda. 

Thyroid  extract  has  been  recommended  as  almost  a 
specific  in  a  long  list  of  diseases,  but  the  indiscriminate 
use  of  the  drug  is  to  be  condemned,  as  large  doses  are 
dangerous  and  small  doses  frequently  repeated  may  per- 
manently impair  the  patient's  health.  It  is  a  poison  and 
should  never  be  prescribed  unless  the  case  is  kept  under 
observation  while  it  is  being  administered. 

I  would  like  to  report  a  number  of  cases  suffering  from 
widely  varying  symptoms  that  I  have  treated  and  relieved 
by  the  use  of  thyroid  extract,  but  the  time  at  my  disposal 
for  the  preparation  of  this  paper  has  been  too  limited 
to  allow  me  to  look  up  their  histories  and  records.    I  must 

194 


HYPOTHYROIDISM 


content  myself,  therefore,  in  being  suggestive  rather  than 
explicit  and  simply  state  that  I  have  personally  found 
the  substitution  thyroid  treatment  of  unquestioned  benefit 
in  selected  cases  embraced  in  the  following  heads : 

1.  Cretinism. 

2.  Myxedema  (spontaneous  and  post-operative). 

3.  Parenchymatous  goitre — especially   in   girls   about 
the  age  of  puberty. 

4.  Amenorrhoea  and  chlorosis. 

5.  Absence  or  failure  of  sexual  desire  or  power. 

6.  Obesity. 

7.  Eczema  of  the  dry  or  scaly  type. 

8.  Delayed  union  of  fractures. 

9.  Certain  neuropathic  conditions  where  the  patient 
is  apathetic  and  drowsy  with  slow  pulse  and  cold  skin. 


195 


The  Influence  of  the  General  Condition 

of  the  Patient  on  the  Result  of  a 

Surgical  Operation* 

There  are  some  operations,  such  as  for  the  relief  of  a 
strangulated  hernia  or  the  removal  of  a  gangrenous  ap- 
pendix, which  are  so  urgently  demanded  for  the  imme- 
diate purpose  of  saving  life,  that  the  surgeon  has  no 
choice,  and  nothing  is  considered  but  the  one  great  need. 
These  are  imperative  operations,  and  must  be  done  re- 
gardless of  risk.  There  are  other  operations,  such  as  for 
the  correction  of  deformities  or  the  relief  of  some 
chronic  ailment,  which,  however  desirable,  are  not  essen- 
tial to  the  life  of  the  patient.  These  are  elective  opera- 
tions, and  should  not  be  undertaken  without  carefully 
considering  the  danger  to  be  incurred  on  the  one  hand 
and  the  benefit  to  be  hoped  for  on  the  other. 

In  estimating  the  risk  of  an  operation,  the  modern 
surgeon  is  too  apt  to  base  his  opinion  on  the  statistics 
contained  in  text-books  and  encyclopedise.  Figures  are 
proverbially  unreliable.  Thus,  for  instance,  the  statistics 
of  old  operations,  such  as  ligations  and  amputations,  are 
usually  a  record  of  pre-antiseptic  surgery,  and  do  not 
represent  the  work  of  today ;  while  the  statistics  of  more 
recent  operations,  such  as  thyroidectomy  or  gastroenter- 
ostomy, are  usually  the  record  of  master-workmen 
like  Kocher  and  the  Mayos,  and  do  not  represent  the 


*  Read  at  a  meeting  of  the  Rochester  Surgical  Club,  Rochester, 
Minn.,  August,  1907. 

197 


INFLUENCE  OF  THE  GENERAL  CONDITION 

danger  of  these  operations  in  the  hands  of  the  average 
surgeon. 

In  deciding  whether  or  not  to  advise  a  patient  to 
undergo  an  elective  operation,  the  following  factors 
should  be  considered : 

First,  the  gravity  of  the  operation  and  the  relief  to  he 
expected  from  its  successful  issue.  There  is  no  operation 
devoid  of  risk,  and  some  are  attended  by  great  danger. 
Patients  are  occasionally  unreasonable,  and  insist  on  hav- 
ing a  serious  operation  done  to  rid  themselves  of  a  more 
or  less  fancied  ailment.  Unless  the  operation  is  safe  and 
there  is  a  reasonable  assurance  of  the  patient  being  ma- 
terially benefited,  he  should  not  be  subjected  to  an  elec- 
tive surgical  ordeal. 

Second,  the  ability  and  experience  of  the  operator.  No 
courageous  doctor  should  fail  to  undertake  an  opera- 
tion if  the  patient's  condition  is  argent,  if  delay  means 
death,  and  if  no  more  experienced  surgeon  is  available. 
Competency  is  a  relative  term,  and  the  man  on  the 
ground  should  endeavor  to  afford  relief,  or  else  he  fails 
to  measure  up  to  his  responsibility.  It  is  different,  how- 
ever, when  the  disease  is  a  chronic  one,  and  the  patient 
could  be  safely  moved  to  a  hospital,  or  await  the  arrival 
of  a  surgeon  from  a  neighboring  city.  A  patient  is  en- 
titled to  the  best  possible  prospect  for  prolonged  life  or 
restored  health  that  his  resources  permit.  No  con- 
scientious surgeon  should  undertake  an  operation  with- 
out asking  himself  whether  he  has  the  skill  to  do  the 
work  satisfactorily.  In  many  cases  he  can  honestly 
answer  the  question  in  the  affirmative.  In  some  cases, 
while  there  may  be  a  doubt  in  his  mind,  he  is  justified 
in  operating  by  the  fact  that  the  patient  has  not  the  phy- 

198 


OF  PATIENT  ON  RESULT  OF  OPERATION 

sical  strength  to  bear  transportation,  or  the  financial 
means  to  bring  a  surgeon  from  a  distance.  In  other  cases, 
however,  the  surgeon  must  recognize  his  inferiority  to 
other  men  in  the  profession  who  devote  their  lives  to 
special  lines  of  work,  and  when  the  patient  has  the  physi- 
cal and  the  pecuniary  power  to  secure  their  services  it  is 
his  duty  to  place  the  case  in  their  hands.  This  obliga- 
tion is  so  universally  recognized  that  the  sacrifice  it  en- 
tails is  not  often  appreciated  by  the  laity,  and  sometimes 
not  by  the  class  of  the  profession  which  is  benefited. 

Third,  the  general  condition  of  the  patient,  or  the  con- 
sideration of  the  personal  factors  in  the  individual  case 
which  influence  the  result  of  the  operation.  It  is  often 
said — sometimes  seriously,  sometimes  satirically  and 
sometimes  truly — that  the  operation  was  a  success,  but 
the  patient  died.  In  such  a  case  the  indications  for  the 
operation  may  have  been  plain,  but  the  contraindications 
were  either  overlooked  or  disregarded.  The  operation 
may  have  completely  corrected  the  condition  from  which 
the  patient  suffered ;  it  may  have  been  perfect  in  its  tech- 
nique and  brilliant  in  its  execution,  but  the  patient  may 
have  lost  his  life  from  some  complication  which  could 
have  been  foreseen  by  more  careful  preliminary  investi- 
gation. Many  surgeons  have  had  uncontrollable  hemor- 
rhage to  follow  the  removal  of  a  small  tumor,  owing  to 
the  patient  having  hemophilia,  or  have  had  gangrene  de- 
velop in  a  wound,  owing  to  the  existence  of  diabetes,  or 
have  had  suppression  of  urine  to  follow,  owing  to  the 
presence  of  nephritis. 

Sir  James  Paget,  in  one  of  his  classical  lectures,  says : 
''Never  decide  upon  an  operation,  even  of  trivial  kind, 
without  first  examining  the  patient  as  to  the  risk  of  his 

199 


INFLUENCE  OF  THE  GENERAL  CONDITION 

life.  You  should  examine  him  with  at  least  as  much  care 
as  you  would  for  life  insurance.  It  is  surely  at  least  as 
important  that  a  man  should  not  die  or  suffer  serious 
damage  after  an  operation,  as  that  his  life  should  be  safe- 
ly insured  for  a  few  hundred  pounds." 

Two  separate  and  independent  examinations  should  be 
made  of  every  surgical  patient — the  first  for  the  purpose 
of  diagnosis  and  the  determination  of  the  condition  to 
be  corrected;  and  the  second  for  the  purpose  of  prog- 
nosis, or  the  determination  of  the  safety  of  the  operation. 
In  forming  an  estimate  of  the  latter  many  factors  have 
to  be  taken  into  consideration,  such  as  age,  sex,  race, 
habits  of  life,  constitutional  diseases  and  visceral  dis- 
orders. In  discussing  these  under  separate  headings  much 
use  has  been  made  of  an  article  by  Sir  Frederick  Treves, 
who  acknowledges  a  similar  indebtedness  to  the  writings 
of  Sir  James  Paget. 

Age.  As  a  general  proposition  it  may  be  stated  that 
patients  at  either  extreme  of  life  are  poor  subjects  for 
surgery. 

Children  under  five  years  of  age  take  anesthetics  badly, 
often  suffer  severe  shock  from  only  moderate  loss  of 
blood,  and  are  difficult  to  manage  during  convalescence. 
They  are  liable  to  gastro-intestinal  disturbances,  especially 
in  hot  weather,  and  frequently  are  the  victims  of  chicken- 
pox,  measles,  or  other  infectious  diseases  to  which  they 
are  susceptible.  On  the  other  hand,  owing  to  the  ener- 
getic cell  activity  of  the  period  of  growth,  their  tissues 
heal  rapidly  and  are  not  prone  to  suppuration.  In  operat- 
ing on  children  avoid,  if  possible,  the  period  of  first 
dentition,  as  they  are  liable  to  digestive  disturbances  and 
to  convulsions,  and  apt  to  develop  a  high  temperature 

200 


OF  PATIENT  ON  RESULT  OF  OPERATION 

from  slight  provocation.  Use  chloroform  as  an  anes- 
thetic, and  avoid  the  infliction  of  long-continued  pain. 
Especial  care  should  be  taken  to  prevent  loss  of  blood  or 
body  heat.  Dressings  should  be  carefully  watched  and 
changed  as  often  as  soiled.  Usually  no  attempt  should  be 
made  to  keep  the  child  in  bed,  but,  from  the  first,  it 
should  be  permitted  to  lie  on  the  mother's  lap  or  be  car- 
ried about  in  her  arms. 

The  period  from  the  fifth  to  the  fifteenth  year  is  the 
golden  age  of  surgery.  Hence  the  mortality  is  least  and 
the  results  best  from  operations  of  almost  every  kind. 
This  is  due  to  the  fact  that  metabolic  processes  are  ac- 
tive and  resistance  to  infection  vigorous ;  that  the  various 
organs  of  the  body  are  normal  and  perform  their  func- 
tions satisfactory ;  that  the  nervous  system  is  stable  and 
uninfluenced  by  regrets  for  the  past  or  fears  for  the 
future ;  and  finally,  that  the  reason  and  will  of  the  patient 
have  developed  sufficiently  for  the  surgeon  to  secure  their 
acquiescence  and  co-operation. 

Between  the  twentieth  and  fortieth  years  the  mor- 
tality of  operations  greatly  increases.  This  is  due  to 
sexual  development,  attended  by  the  possibility  of  ex- 
cesses, abnormalities  and  diseases;  also,  to  the  cares  and 
responsibilities  of  maturity,  often  leading  to  neurasthenia 
from  excessive  work  and  worry.  And  finally  there  may 
be  superadded  the  injurious  results  of  addiction  to  to- 
bacco, whiskey  or  other  drugs,  and  of  other  forms  of 
dissipation. 

In  patients  past  forty  years  of  age  the  mortality  from 
operations  is  nearly  three  times  as  great  as  in  patients 
under  twenty.  As  a  rule,  old  people  are  severely 
shocked  by  loss  of  blood  or  body  heat ;  their  wounds  heal 

201 


INFLUENCE  OF  THE  GENERAL  CONDITION 

slowly,  and  their  tissues  have  little  power  to  resist  in- 
fection. They  are  head-strong  and  rebellious,  and  in- 
tolerant to  confinement.  Their  organs  of  assimilation 
and  excretion  are  impaired,  and  their  stomachs  and  kid- 
neys liable  to  break  down.  Taken  all  in  all,  old  age  is 
a  greater  bar  to  surgery  than  any  other  complication, 
unless  it  be  chronic  alcoholism.  It  must  be  remembered, 
however,  that  senility  is  not  measured  in  years.  Sur- 
gically speaking,  a  man  is  as  old  as  his  arteries.  In  im- 
pressing this  point  Sir  James  Paget  says :  "They  that 
are  fat  and  bloated,  flabby  of  texture,  torpid,  wheezy, 
and  incapable  of  exercises,  looking  older  than  their  years, 
are  very  bad. 

"They  that  are  fat,  florid  and  plethoric,  firm  skinned, 
and  with  good  muscular  power,  clear-headed,  and  willing 
to  work  like  younger  men,  are  not,  indeed,  good  sub- 
jects for  operation,  but  they  are  scarcely  bad. 

"The  old  people  that  are  thin  and  dry  and  tough, 
clear-voiced  and  bright-eyed,  with  good  stomachs  and 
strong  wills,  muscular  and  active,  are  not  bad ;  they  bear 
all  but  the  largest  operations  very  well." 

The  brilliant  results  of  Young  and  others  in  operat- 
ing on  old  men  for  prostatic  enlargement  show  that 
modern  surgery,  with  its  short  period  of  anesthesia, 
diminished  loss  of  blood,  freedom  from  infection,  and  pro- 
visions for  adequate  drainage,  has  made  it  safe  to  do 
operations  on  the  aged  which,  only  a  short  time  ago  would 
have  been  unjustifiable. 

Sex.  Other  things  being  equal,  women  bear  opera- 
tions better  than  men.  This  is  due  to  the  fact  that  they 
are  designed  for  maternity  and  are  naturally  endowed 
w^'th  more  passive  endurance;  that  they  are  more  con- 

202 


OF  PATIENT  ON  RESULT  OF  OPERATION 

fiding  and  trustful  and  place  greater  confidence  in  the 
assurances  of  the  surgeon;  that  they  are  more  tolerant 
to  confinement  to  bed,  because  they  are  not  accustomed 
to  active  out-door  life;  and  finally,  they  are*  more  tem- 
perate and  regular  in  their  lives,  and  not  as  frequently 
the  victims  of  excesses  in  food  and  drink. 

On  the  other  hand,  menstruation,  pregnancy,  lactation 
and  the  phenomena  of  the  menopause  give  to  the  sex  the 
possibility  of  complications  to  which  the  male  is  not  sub- 
ject. As  a  rule,  operations  should  be  avoided  during  men- 
struation, as  the  period  is  frequently  attended  with  ner- 
vous and  digestive  disturbances.  The  time  of  election, 
especially  in  gynecological  work,  is  the  two  weeks  midway 
between  the  completion  of  one  period  and  the  beginning 
of  the  next.  In  emergencies,  however,  an  operation  may 
be  done  during  menstruation  without  misgivings,  as  usu- 
ally no  ill  effects  result. 

It  is  also  undesirable  to  do  an  operation  of  election 
during  pregnancy,  as  it  entails  the  possibility  of  miscar- 
riage and  of  kidney  break-down.  The  danger  is  more 
theoretical  than  real,  however,  as  hundreds  of  abdomi- 
nal sections  have  been  done  on  pregnant  women,  for 
appendicitis  and  other  abdominal  diseases  without  inter- 
ference with  gestation. 

It  is  also  inadvisable  to  operate  during  lactation,  be- 
cause the  woman's  strength  and  resistance  are  below 
par,  and  if  she  continues  to  nurse  the  child  she  will  have 
an  undue  tax  upon  her;  while  if  she  ceases  to  do  so, 
there  will  be  the  danger  of  trouble  with  her  breast. 

Race.  The  influence  of  race  on  the  result  of  an  opera- 
tion is  a  question  of  interest,  but  not  of  great  practical 
value.     It   is   stated   that   a   Chinaman   makes   the   best 

203 


INFLUENCE  OF  THE  GENERAL  CONDITION 

patient  on  earth.  In  America,  especially  in  the  Southern 
States,  there  is  good  opportunity  to  contrast  the  respec- 
tive resistence  of  the  Caucasian  and  the  Negro.  Sur- 
geons of  large  experience  in  operating  on  both  races  are 
practically  unanimous  in  the  opinion  that  the  black  man 
is  a  better  subject  than  the  white  man.  This  does  not 
apply  to  the  mulatto,  for  he  follows  the  rule  of  the  mon- 
grel, and  has  the  vices  of  both  parents  and  the  virtues  of 
neither.  It  is  obvious  even  in  the  life  of  an  individual 
that  the  pure  negro  is  losing  the  immunity  formerly  en- 
joyed to  certain  diseases,  and  is  developing  predisposi- 
tions which  render  him  a  less  favorable  subject  for  opera- 
tion. Before  the  Civil  War  insanity  was  almost  unknown 
in  the  race;  tuberculosis  was  not  common,  and  venereal 
diseases  of  rare  occurrence.  With  education  and  syphili- 
zation  he  is  now  the  victim  of  various  nervous  disorders ; 
with  unhygienic  surroundings  and  scant  clothing  he  is  a 
frequent  victim  of  the  Great  White  Plague,  and  with  im- 
proper food,  eaten  at  irregular  intervals,  his  digestion 
has  become  impaired,  and  he  is  suffering  more  and  more 
frequently  from  gall-stones,  appendicitis,  and  diseases  of 
the  kidneys.  The  day  will  come  when  the  degeneration 
of  the  whole  race  will  have  reached  a  point  to  make  it  an 
accepted  fact  that  they  are  poor  subjects  for  surgical 
work. 

Vigor  and  Weakness. — Paradoxical  as  it  may  sound, 
the  strong,  robust  man  frequently  does  not  make  as  good 
a  surgical  patient  as  one  who  is  feeble  and  wasted  by 
disease.  He  may  have  huge  limbs  and  mighty  strength ; 
he  may  never  have  had  an  illness  in  his  life,  and  boast 
the  constitution  of  an  ox,  but  he  is  a  poor  subject  for  the 
surgeon's  knife.     He  is  accustomed  to  fresh  air  and  an 

204 


OF  PATIENT  ON  RESULT  OF  OPERATION 

active  life ;  his  blood  vessels  are  full  and  oxygenation  of 
the  tissues  is  rapid.  His  food  has  been  large  in  quantity 
and  gross  in  quality.  When  misfortune  overtakes  him 
there  is  no  time  to  accommodate  himself  to  new  condi- 
tions, and  the  whole  habit  of  his  life  is  suddenly  changed. 
To  this  is  added  the  shock  of  his  accident,  the  horror  of 
an  operation,  and  the  dread  of  the  future.  Just  the  con- 
trary is  true  with  the  chronic  invalid,  who  has  been  accli- 
mated to  bed  life  by  long  weeks  of  invalidism,  whose  cir- 
culation, respiration,  and  digestion  have  become  adjusted 
to  his  condition,  and  who  has  been  brought  to  view  the 
approaching  operation  as  a  means  of  relief  and  pain  and 
restoration  to  health.  Of  the  two  types  described  the  last 
will  be  well  first. 

Obesity. — As  a  rule,  a  fat  patient  is  a  bad  patient. 
If  the  obesity  is  hereditary  and  the  general  health  good, 
it  is  not  as  bad  as  when  the  fat  is  due  to  gluttony,  in- 
dolence, or  beer-drinking.  An  obese  patient  is  an  ele- 
phant on  your  hands.  He  usually  breathes  with  difficulty 
and  cannot  assume  a  recumbent  position.  It  is  hard  to 
move  him  in  bed,  and  difficult  to  prevent  the  formation 
of  bed-sores.  The  skin  is  usually  thin  from  pressure,  and 
its  edges  difficult  to  approximate.  The  subcutaneous  fat 
has  little  vitality  and  readily  breaks  down  and  liquefies. 
Infection  once  taking  place,  pus  burrows  far  and  wide, 
and  is  drained  with  great  difficulty.  Sometimes  such 
patients  die  suddenly  from  fat  embolism;  again,  they  be- 
come exhausted  and  prove  an  easy  victim  to  intercurrent 
diseases.  If  recovery  takes  place,  convalescence  is  always 
tedious  and  prolonged. 

Alcoholism. — The  most  unpromising  patient  who  ever 
comes  to  a  surgeon  is  the  chronic  alcoholic.      Constant 

205 


INFLUENCE  OF  THE  GENERAL  CONDITION 

drinkers  who  are  never  drunk,  and  yet  who  are  never 
sober,  are  worse  subjects  than  those  who  get  on  periodic 
sprees.  The  gravity  of  the  risk  in  the  individual  case  will 
depend  on  the  length  of  time  the  individual  has  taken  sti- 
mulant; the  average  amount  consumed  daily;  the  pres- 
ence or  absence  of  tremor  of  the  hand  or  alteration  of 
the  knee-jerk;  the  existence  of  gastritis,  as  indicated  by 
anorexia,  nausea  or  vomiting;  and  the  condition  of  the 
liver,  kidneys,  heart,  and  blood  vessels.  No  operation 
except  the  most  imperative  should  be  done  on  the  alco- 
holic, because  of  the  danger  of  administration  of  the 
anesthetic,  because  of  the  depraved  condition  of  the  tis- 
sues and  consequent  lack  of  resistance  to  infection,  be- 
cause of  the  liability  of  the  kidneys  to  stall  or  the  heart 
to  run  away,  and  because  of  the  danger  of  the  develop- 
ment of  wild  and  uncontrollable  delirium.  When  an 
operation  is  unavoidable,  but  not  immediately  necessary, 
the  patient  should  be  prepared  for  it  by  diminishing  or 
withdrawing  the  stimulant.  When  an  immediate  opera- 
tion is  necessary,  it  is  better  to  continue  the  alcohol  until 
the  period  of  greatest  danger  is  passed. 

Affections  of  the  Nervous  System. — Hysterical  patients 
usually  give  a  great  deal  of  trouble  before  the  operation, 
but  do  very  well  after  the  ordeal  is  over.  A  nervous  wo- 
man who  wishes  to  tell  of  the  surgical  adventures  of  her 
friends,  who  desires  to  discuss  every  step  and  detail  of 
her  own  operation  and  tell  how  she  wishes  her  case 
managed,  and  who  is  possessed  of  exaggerated  fears  as  to 
the  complications  which  may  develop  or  the  ultimate  re- 
sult which  may  follow,  usually,  after  the  operation,  be- 
comes a  model  patient.     Her  imagination   enters  upon 

206 


OF  PATIENT  ON  RESULT  OF  OPERATION 

fresh  fields  and  she  becomes  hopeful  and  courageous,  and 
at  once  begins  to  plan  a  new  life  of  activity. 

The  neurasthentic,  however,  is  a  different  subject,  and 
woe  betide  the  incautious  surgeon  who  operates  on  one. 
Occasionally  neurasthenia  may  be  due  to  chronic  appendi- 
citis, uterine  displacement,  or  some  other  cause  which 
can  be  corrected  and  the  patient  cured.  But  in  a  large 
majority  of  cases  the  neurasthenia  is  due  to  a  disturbance 
of  the  general  body  nutrition,  and  no  operation  will 
prove  of  benefit.  The  victim  of  neurasthenia  wears  out 
the  patience  of  his  family  and  friends,  and  in  order  to 
secure  a  sympathetic  listener,  and  in  order  to  demonstrate 
to  the  community  the  serious  nature  of  his  disease,  he 
goes  from  surgeon  to  surgeon  and  from  hospital  to  hospi- 
tal, offering  himself  as  a  bloody  sacrifice  to  his  curious 
form  of  egotism,  and  glorying  in  his  martyrdom.  Sur- 
gery does  this  class  of  patients  no  good,  but  deepens, 
rather  than  relieves,  the  neurasthenia. 

The  insane  are  usually  good  subjects  for  surgical  opera- 
tion. The  regular  life  of  an  asylum  is  conducive  to  good 
health,  and  the  absence  of  mental  anxiety  on  the  part  of 
the  patient  is  a  favorable  factor.  Mayo,  who  has  done 
a  great  deal  of  work  on  this  class  of  cases,  states  that 
they  are  entitled  to  just  the  same  surgical  treatment  as 
the  sane — no  more,  no  less.  In  other  words,  insane  peo- 
ple should  be  operated  on  to  relieve  them  of  hernia,  gall- 
stones, and  abdominal  tumors,  but  hernia,  gall-stones,  and 
abdominal  tumors  should  not  be  operated  on  to  cure  the 
patient  of  insanity. 

Syphilis  does  not  usually  increase  the  risk  of  a  surgical 
operation.  Wounds  made  during  the  full  bloom  of  the 
secondary  stage  heal  kindly,  and  operations  done  on  ter- 

207 


INFLUENCE  OF  THE  GENERAL  CONDITION 

tiary  lesions  usually  do  well.  The  danger  in  operating  in 
the  early  stages  of  syphilis  is  rather  one  to  the  surgeon 
than  to  the  patient,  as  the  blood  is  infectious. 

Gout  has  no  effect  upon  the  result  of  an  operation,  un- 
less it  has  existed  sufficiently  long  to  produce  cardiac  or 
renal  changes.  It  is,  of  course,  not  wise  to  operate  during 
an  acute  attack  of  the  disease,  and  it  must  also  be  remem- 
bered that  an  operation  sometimes  precipitates  an  attack 
in  a  person  predisposed  to  the  disease. 

Hemophilia  contraindicates  a  surgical  operation,  un- 
less urgent  and  required  to  save  life.  Fortunately,  the 
subjects  of  hemophilia  do  not  always  bleed.  A  case  is 
in  mind  where  a  man  was  brought  to  the  hospital  with 
gangrenous  appendicitis,  and  who  gave  a  history  of  hav- 
ing suffered  repeatedly  from  almost  fatal  hemorrhage 
after  trivial  injuries.  After  consultation  a  section  was 
determined  on  as  the  only  hope  for  life.  It  was  per- 
formed with  less  than  the  usual  loss  of  blood. 

Anemia,  or  a  deficiency  of  either  hemoglobin  or  red 
blood  cells,  is  often  a  contraindication  to  an  operation. 
Mikulicz  states  that  a  hemoglobin  percentage  below  30, 
or  a  red  blood  count  below  3,500,000  should  postpone 
operative  intervention  until  the  blood  is  enriched  by  medi- 
cal treatment.  While  this  is  a  safe  rule  to  follow,  it  has 
its  exceptions.  The  lives  of  women  have  often  been 
saved  by  hysterectomies,  whose  blood  findings  were  be- 
low this  minimum,  owing  to  profuse  and  uncontrollable 
uterine  hemorrhage. 

Malaria  and  an  injury  or  operation  have  a  reciprocal 
relation  one  with  the  other.  Malaria  may  cause  pain, 
hemorrage  or  inflammatory  changes  at  the  site  of  injury, 
which  assumes  an  intermittent  type  and  yield  to  adminis- 

208 


OF  PATIENT  ON  RESULT  OF  OPERATION 

tration  of  quinine.  Again,  an  injury  or  operation  in- 
flicted on  a  person  the  victim  of  malaria  may  markedly 
aggravate  the  disease,  or  induce  a  fresh  onset  of  ague ,  or 
again,  it  will  make  active  symptoms  in  a  person  who  is 
not  known  to  be  infected. 

Diabetes  is  a  contraindication  to  an  operation  of  elec- 
tion. The  tissues  of  a  diabetic  patient  possess  little  power 
of  regeneration,  and  have  so  little  resistance  to  infection 
that  inflammation,  suppuration,  and  gangrene  are  almost 
certain  to  develop.  Surgery  on  diabetics  should  only  be 
done  when  most  imperatively  demanded,  as  often,  when 
the  sugar  in  the  urine  has  been  decreased  to  an  insignifi- 
cant amount  by  weeks  of  dietetic  treatment,  it  will  reap- 
pear in  large  quantities  immediately  after  the  operation, 
and  the  patient  die  in  diabetic  coma. 

Cardiac  Disease. — Valvular  disease  of  the  heart  is  be- 
lieved by  the  laity  and  by  most  of  the  profession  to  add 
greatly  to  the  risk  of  the  anesthetic  and  to  the  danger  of 
death  from  complications  following  the  operation.  This 
does  not  seem  substantiated  by  facts.  Many  thousands 
of  patients  with  valvular  heart  disease  are  operated  upon 
every  year,  and  it  is  exceedingly  rare  that  any  bad  effect 
is  produced ;  and  but  a  very  small  proportion  of  the  pa- 
tients who  die  from  chloroform  or  ether  are  found  to 
have  been  the  victim  of  organic  heart  disease.  So  far  as 
convalescence  after  the  operation  is  concerned,  patients 
with  heart  trouble  are  usually  markedly  improved  by  the 
enforced  rest  and  confinement  to  bed.  A  dilated  or  fatty 
heart  is  much  more  to  be  feared  than  one  with  valvular 
lesion,  especially  if  there  is  adequate  compensation. 

Renal  Diseases. — It  was  formerly  thought  that  the 
presence  of  albumen  or  casts  in  the  urine  indicated  grave 

2C9 


INFLUENCE  OF  THE  GENERAL  CONDITION 

organic  change  in  the  kidney,  and  was  a  bar  to  surgery. 
This  may  have  been  the  case  with  the  crude  tests  of  the 
older  pathologists,  but  it  is  certainly  not  so  today,  for  the 
modern  laboratory  man  finds  albumen  and  casts  in  a 
great  proportion  of  the  specimens  submitted  to  him.  Dr. 
Osier  has  emphasized  this  in  a  recent  article  entitled, 
*'The  Advantages  of  Having  a  Few  Casts  in  the  Urine 
After  a  Man  Reaches  Sixty  Years  of  Age."  Certain 
forms  of  nephritis,  however,  add  greatly  to  the  danger  of 
an  operation,  and  all  surgeons  occasionally  lose  patients 
from  suppression  of  urine  followed  by  uremic  convul- 
sions. No  operation  of  election  should  be  done  on  a  pa- 
tient suffering  with  advanced  Bright's,  and  when  the  ur- 
gency of  the  case  is  such  that  an  operation  has  to  be  done, 
the  patient  should  be  carefully  prepared  by  dietetic  and 
eliminative  treatment  before  the  operation,  and  the  kid- 
neys kept  active  afterwards  by  the  use  of  spartine  and  the 
administration  of  large  quantities  of  water  by  mouth  or 
rectum. 

Respiratory  Tract. — Bronchitis,  pneumonitis,  and 
phthisis  pulmonalis  are  serious  bars  to  surgery,  inasmuch 
as  they  make  the  administration  of  the  anesthetic  difficult 
and  dangerous,  and  complicate  the  after-treatment  by 
coughing,  embarrased  breathing,  and  imperfect  oxygena- 
tion. In  acute  inflammation  of  the  lungs  operations 
should  be  postponed,  and  in  chronic  trouble  they  should 
not  be  done  except  to  meet  real  indications. 

Alimentary  Tract. — Gastric  dyspepsia,  intestinal  indi- 
gestion, diarrhea,  and  constipation  are  all  conditions  to 
be  corrected  prior  to  an  operation.  The  prognosis  is  bad 
when,  to  the  toxins  of  disease,  is  added  the  poison  pro- 
duced by  putrefaction  of  gastric  and  intestinal  contents. 

210 


OF  PATIENT  ON  RESULT  OF  OPERATION 

In  correcting  the  conditions  named  food  should  be  steri- 
lized, the  mouth  should  be  repeatedly  disinfected,  the 
stomach  should  be  properly  irrigated,  and  intestinal  anti- 
septics, together  with  purgatives,  should  be  judiciously 
administered. 

In  disease  of  the  liver,  especially  when  the  patient  is 
jaundiced,  the  danger  of  hemorrhage  should  be  deter- 
mined by  testing  the  coagulability  of  the  blood,  and,  ex- 
cept in  cases  of  great  urgency,  operations  should  be  post- 
poned until  the  cholemia  subsides,  or  until,  by  the  ad- 
ministration of  calcium  chloride  or  other  remedies,  the 
danger  of  uncontrollable  bleeding  can  be  removed. 


211 


Surgical  Shock  * 

It  has  long  been  known  that  patients  who  met  with 
accidents  or  underwent  operations,  not  of  themselves 
necessarily  fatal,  frequently  died  without  apparent  cause. 
It  is  only  within  the  last  century  that  it  has  been  known 
that  these  cases  died  of  shock.  As  soon  as  the  condition 
was  recognized  it  was  studied  both  clinically  and  experi- 
mentally by  the  leading  men  of  the  profession,  and  the 
literature  of  the  subject  is  now  large. 

The  writers  of  the  past  generation  had  a  clear  concep- 
tion of  the  causes  and  symptoms  of  shock,  but  they  did 
not  understand  its  nature,  and  hence  the  methods  of  pre- 
vention and  cure  were  inefficient  and  unscientific.  With- 
in the  past  decade  Crile,  of  Cleveland,  a  leader  in  the 
new  school  of  surgical  physiology,  has  done  much  to  work 
out  its  pathology,  and  the  publication  of  his  recent  ar- 
ticles has  revolutionized  the  practice  of  the  profession  in 
dealing  with  the  condition.  There  are  yet  some  appar- 
ently contradictory  facts  to  be  explained  and  certain  prob- 
lems to  be  more  fully  elucidated,  and,  consequently,  it  will 
probably  be  best  to  introduce  the  subject  by  giving  a 
clinical  picture  of  a  typical  case. 

Typical  Case. 
A  patient  who  has  been  subjected  to  a  mutilating  and 
perhaps  bloody,  operation  is  carried  to  the  ward.    When 
placed  in  bed  he  m^es  no  effort  to  move  or  speak,  but 


*  Lecture  reprinted  from  the  Bulletin  of  the  University  College 
of   Medicine,   August,    1908. 

213 


SURGICAL  SHOCK 


lies  staring  at  the  attendants.  His  face  is  white  and  pal- 
Hd,  his  features  pinched,  and  his  eyes  are  sunken  in  their 
sockets  and  encircled  by  black  discoloration.  He  com- 
plains of  no  pain,  expresses  no  anxiety,  and  his  mental 
attitude  is  one  of  complete  indifference.  His  skin  is  cold 
and  bathed  in  a  clammy  sweat.  His  lips  and  nails  are 
blue,  his  pulse  is  rapid  and  thread-like,  or  may  be  im- 
perceptible at  the  wrist.  His  respiration  is  shallow,  sigh- 
ing and  irregular.  A  thermometer  placed  in  the  rectum 
shows  his  temperature  to  be  subnormal.  There  is  no 
muscular  paralysis,  but  the  patient  lies  perfectly  still  and 
is  disinclined  to  move.  There  is  no  unconsciousness,  but 
he  does  not  speak  unless  spoken  to,  and  then  answers 
questions  in  slow  monosyllables.  If  reaction  does  not 
follow,  the  pulse  gets  weaker  and  finally  disappears ;  the 
respiration  becomes  more  shallow,  and  the  skin  clammy 
and  colder,  and  ''this  momentary  pause  in  the  act  of  death 
is  soon  followed  by  the  grim  reality."  A  post  mortem 
examination  shows  no  pathologic  change  to  explain  the 
symptoms. 

Causes  of  Shock. 

Loss  of  Blood. — This  is  by  far  the  most  frequent  cause 
of  shock.  In  fact,  a  sudden  hemorrhage  produces  symp- 
toms so  identical  with  shock  that  it  is  difficult  to  distin- 
guish the  two.  The  more  rapid  the  loss  of  blood  the 
more  severe  the  shock,  and  the  less  the  chance  of 
recovery. 

Loss  of  Heat. — The  abstraction  of  body  heat  by  operat- 
ing in  a  cold  room,  exposing  the  abdominal  or  other  vis- 
cera to  the  air,  or  wetting  the  clothing  of  the  patient  with 

214 


SURGICAL  SHOCK 


solutions  which,  while  warm  at  the  time,  soon  become 
cold,  all  strongly  tend  to  produce  shock. 

Loss  of  Time. — An  operation  which,  if  quickly  done, 
would  produce  no  appreciable  degree  of  shock,  if  unduly 
prolonged,  frequently  is  followed  by  alarming  symptoms. 
This  is  partially  due  to  the  fatigue,  exposure,  and  pro- 
longed anesthesia  to  which  the  patient  is  subjected,  but 
is  also  due  to  the  continued  irritation  of  the  brain  and 
spinal  cord  by  stimuli  from  the  field  of  operation.  Ether 
and  chloroform  prevent  the  appreciation  of  pain,  but 
they  do  not  protect  the  nerve  centers  whose  exhaustion 
causes  shock. 

Mechanical  Injuries. — These  vary  in  degree  from 
rough-handling  of  tissues  by  the  surgeon  to  a  compound 
dislocation  or  crushing  injury  of  a  limb  by  an  accident. 
The  various  tissues  and  organs  of  the  body  have  a  shock- 
producing  power  in  proportion  to  their  nerve  supply, 
and,  consequently,  the  degree  of  shock  will  depend  not 
only  on  the  severity  of  the  trauma,  but  also  on  the  sen- 
sory innervation  of  the  part.  Injuries  to  certain  regions 
of  the  body  are  especially  likely  to  be  followed  by  shock, 
such  as  a  blow  on  the  testicle,  in  the  pit  of  the  stomach, 
or  at  the  angle  of  the  jaw. 

Burns. — The  action  of  intense  heat  on  the  nerve  termi- 
nals of  the  skin  often  produces  profound  shock.  Mum- 
mery has  pointed  out  that  burns  of  the  first  and  second 
degree  produce  more  shock  than  burns  of  the  third  de- 
gree. This  is  due  to  the  fact  that,  in  the  first  case,  the 
nerve  terminals  are  exposed  and  irritated,  whereas,  in  the 
second,  they  are  destroyed.  A  burn  involving  more  than 
one-half  of  the  surface  of  the  body  usually  causes  death 
from  shodk. 

2T5 


SURGICAL  SHOCK 


Perforating  Injuries. — Rupture  of  the  gall  bladder, 
perforation  of  a  gastric,  duodenal  or  typhoid  ulcer,  or 
a  rapidly  fulminating  case  of  appendicitis,  resulting  in 
the  discharge  of  irritating  fluids  into  the  peritoneal  cavity, 
frequently  causes  sudden  and  profound  shock.  It  is  sup- 
posed that  the  pus,  gastric  juices,  or  intestinal  contents 
act  on  the  peritoneum  as  heat  would  act  on  the  skin. 

Mental  Emotions. — The  psychic  condition  of  the  pa- 
tient undoubtedly  influences  the  occurrence  of  shock. 
There  is  no  reason  to  doubt  that  violent  emotions,  such 
as  intense  fear  or  terror,  can  exhaust  the  nervous  power 
and  produce  the  same  results  as  a  physical  injury.  A 
case  is  on  record  where  a  man  who  had  been  sentenced 
to  death  by  bleeding  actually  died  on  hearing  water 
trickle  into  a  basin,  which  he  supposed  to  be  blood  issuing 
from  his  veins.  Another  case  is  quoted  where  a  man 
fainted  and  died,  under  the  impression  that  an  operation 
was  in  progress  when  the  surgeon  was,  in  fact,  only  trac- 
ing with  his  nail  the  line  of  incision  on  his  perineum. 
Brunton  quotes  the  case  of  a  janitor  of  a  college  who  had 
rendered  himself  obnoxious  to  the  students.  One  night 
they  carried  him  to  a  lonely  place,  and  having  dressed 
themselves  in  black,  tried  him  for  his  life.  He  at  first 
affected  to  treat  the  incindent  as  a  joke,  but  was  assured 
by  the  students  that  they  meant  it  in  real  earnest.  He 
was  found  guilty  and  was  told  to  prepare  himself  for 
death.  He  was  blind-folded  and  made  to  kneel  before  a 
block,  and  was  struck  on  the  back  of  the  neck  with  a  wet 
towel.  He  fell  to  the  ground,  and,  to  the  astonishment 
and  horror  of  the  students,  they  found  that  he  was  dead. 

In  addition  to  the  foregoing  exciting  causes  of  shock 
there  is  considerable  influence  exerted  on  its  production 

216 


SURGICAL  SHOCK 


by  the  age,  sex,  temperament,  mental  condition,  and  gen- 
eral health  of  the  individual.  The  young  and  the  old  are 
more  likely  to  suffer  from  shock  than  those  of  middle 
years.  Women,  as  a  rule,  stand  injuries  and  operations 
better  than  men.  Those  of  sanguine  or  nervous  tempera- 
ment suffer  more  from  shock  than  the  lymphatic.  The 
chronic  invalid  usually  stands  surgery  better  than  a  ro- 
bust man,  and  a  patient  who  comes  to  the  operating  table 
confident  and  hopeful  is  less  likely  to  develop  shock  than 
one  possessed  with  gloomy  forebodings  as  to  the  future. 

Pathology  of  Shock. 

Shock  is  stated  by  Crile  to  be  due  essentially  to  an  ab- 
normally low  blood  pressure.  The  normal  blood  pres- 
sure is  dependent  on  three  factors :  First,  a  proper  force 
of  heart  beat;  second,  a  proper  rate  of  heart  beat;  and 
third,  a  proper  peripheral  resistance.  The  effect  of  varia- 
tion of  these  factors  may  be  stated  in  several  definite 
laws: 

1.  The  blood  pressure  must  vary  with  the  rate  of  the 
heart,  if  the  heart  strength  and  peripheral  resistance  re- 
main constant. 

2.  The  blood  pressure  must  vary  with  the  strength  of 
the  heart,  if  the  heart  rate  and  peripheral  resistance  re- 
main constant. 

3.  The  blood  pressure  must  vary  with  peripheral  resis- 
tance, if  the  heart  strength  and  heart  rate  remain  constant. 

4.  The  blood  pressure  may  be  normal  if  one  or  two 
factors  increase,  while  one  or  two  factors  decrease. 

5.  If  all  three  factors  increase,  we  must  have  a  pro- 
portionate increase  in  blood  pressure. 

217 


SURGICAL  SHOCK 


6.  If  all  decrease,  we  must  have  a  proportionate  de- 
crease in  blood  pressure. 

7.  All  three  factors  are  controlled  by  the  nervous 
system. 

Shock  is  due  to  irritating  or  painful  impulses  which 
are  produced  by  accidents  or  operations.  These  impulses 
act  on  the  centers  of  the  brain  and  cord,  first  causing  sti- 
mulation, but  later  resulting  in  exhaustion  or  paralysis. 
They  may  be  of  such  degree  as  at  once  to  overwhelm  the 
centers,  or  they  may  produce  the  same  result  slowly,  by 
acting  continuously  for  a  considerable  period  of  time. 
Crile  believes  that  shock  is  invariably  due  to  paralysis  of 
the,  vaso-motor  centers  and  a  consequent  loss  of  periphe- 
ral resistance.  Howell  believes  that  it  may  also  be  due  to 
feeble  heart  action.  Accepting  the  latter  conclusion,  as 
seems  borne  out  by  clinical  facts,  shock  may  be  defined  as 
a  condition  characterized  by  long  continued  low  blood 
pressure,  due  either  to  partial  or  complete  paralysis  of  the 
vaso-constrictor  centers  and  consequent  lack  of  periphe- 
ral resistance  (vascular  shock),  or  to  alterations  in  the 
rate  and  force  of  the  heart  beat,  due  to  partial  or  com- 
plete loss  of  activity  of  the  cardio-inhibitory  center  (car- 
diac shock). 

Whether  the  low  blood  pressure  be  due  to  vascular  or 
cardiac  causes,  the  result  is  the  same.  The  face  becomes 
blanched,  the  skin  pallid,  the  temperature  subnormal,  the 
pulse  weak  and  thread-like,  the  respiration  shallow  and 
sighing,  the  muscular  power  impaired,  and  cerebration 
blunted.  These  changes  are  due  to  lack  of  sufficient  cir- 
culation to  maintain  normal  physiological  function.  The 
blood  does  not  flow  freely  through  the  arterial  system, 
but  accumulates  in  the  dilated  venous  trunks,  especially 

218 


SURGICAL  SHOCK 


in  the  abdominal  region.  In  other  words,  the  arterial 
system  bleeds  into  the  dilated  venous  system,  and,  as  the 
old  writers  put  it.  the  patient  may  bleed  to  death  into  his 
own  vessels. 

Symptoms  of  Shock. 

Facial. — The  expression  of  the  face  is  frequently  so 
altered  that  it  is  difficult  to  recognize  the  individual.  The 
pupils  are  but  slightly  changed,  but  the  eyes  are  sunken 
in  their  sockets,  the  lids  half  closed,  and  the  areolar 
around  them  darkened.  The  nose  is  small  and  shriveled, 
and  the  lips  are  thin,  pale,  and  usually  parted. 

Cutaneous. — The  skin  has  a  sickly  pallor,  and  the  sur- 
face of  the  body  is  cold  and  bathed  in  clammy  sweat. 
The  fingers  and  nails  are  of  a  bluish  color,  and  the  skin 
on  the  palmar  aspect  of  the  hands  lies  in  loose  folds. 

Mental. — The  patient  is  not  unconscious,  but  the  men- 
tal faculties  are  less  acute  than  normal.  He  complains 
of  no  pain,  expresses  no  anxiety  as  to  his  future,  and 
shows  no  interest  in  what  is  being  done  for  him.  If 
asked  a  question,  he  will  reply  intelligently,  but  slowly 
and  with  effort. 

Miiscidar. — There  is  no  paralysis,  but  reflexes  are  di- 
minished, and  the  voluntary  and  involuntary  muscular 
systems  are  greatly  relaxed.  The  patient  lies  in  the  pos- 
ture in  which  he  is  put,  and  does  not  voluntarily  change 
his  position  or  move  his  limbs.  There  is  frequently  loss 
of  control  of  the  sphincters,  with  involuntary  discharge 
of  urine  and  feces. 

Respiratory. — Respirations  are,  as  a  rule,  quickened, 
irregular,  and  shallow.     In  grave  cases  there  is  gasping 

219 


SURGICAL  SHOCK 


although  air  hunger  is  never  as  marked  as  in  pure 
hemorrhage. 

Circulatory. — The  condition  of  the  pulse  varies  with 
the  degree  of  shock.  It  is  usually  small,  thread-like,  and 
at  times  imperceptible.  The  strength  of  the  pulse  is  an 
important  guide  to  the  surgeon  in  making  a  prognosis. 

Temperature. — The  temperature  is  subnormal,  a  ther- 
mometer placed  in  the  rectum  frequently  registering  as 
low  as  95°  or  96°  F.  Much  lower  temperatures  are  re- 
ported from  observations  taken  in  the  axilla,  but  these  are 
not  reliable. 

Terminations. 

Shock  may  terminate  in  either  of  two  ways : 
Reaction. — If  recovery  ensues,  the  patient  begins  to 
move  about  in  bed,  turns  on  his  side,  and  perhaps  vomits. 
The  pulse  gets  fuller  and  slower;  the  respiration  deeper 
and  more  regular;  the  skin  warmer  and  dryer,  until  fin- 
ally there  is  a  return  of  the  system  to  its  normal  condition. 
Death. — In  fatal  cases  of  shock,  the  pulse  grows  weak- 
er and  finally  disappears.  Respiration  becomes  shallow 
and  irregular.  The  skin  grows  colder ;  the  patient  gradu- 
ally becomes  unconscious ;  the  sphincters  relax,  and  he 
slowly  expires. 

Diagnosis  of  Shock. 

The  diagnosis  of  shock,  at  the  present  time,  cannot  be 
made  with  scientific  accuracy,  and  must  be  based  on  the 
personal  experience  of  the  surgeon.  It  is  made  on  the 
symptoms  above  described,  especially  the  weak,  rapid 
pulse,  the  cold,  pallid  skin,  the  subnormal  temperature 
and  the  curious  condition  of  the  mental  faculties. 

220 


SURGICAL  SHOCK 


The  differential  diagnosis  between  traumatic  shock  and 
hemorrhage,  syncope,  fat  embohsm,  hysteria,  and  other 
conditions  with  which  it  may  be  confused,  is  sometimes 
difficult.  In  hemorrhage,  the  symptoms  are  usually  grad- 
ual in  onset  and  progressive.  The  patient  often  faints,  re- 
covers, and  faints  again;  and  is  usually  restless,  tossing 
from  side  to  side  in  bed,  and  expressing  great  anxiety 
about  his  condition.  In  syncope  there  is  usually  prelimi- 
nary nausea,  ringing  in  the  ears  and  dizziness,  and  when 
the  actual  attack  ensues  the  patient  becomes  completely 
unconscious.  In  fat  embolism,  the  symptoms  usually  de- 
velop twenty-four  to  forty-eight  hours  after  the  injury, 
when  there  is  sudden  pallor,  irregular  heart  action,  diffi- 
cult breathing,  and  perhaps  convulsions.  This  occurs 
chiefly  after  fractures  or  operations  on  bone.  Fat  will 
be  found  in  the  urine.  In  hysteria  there  are  usually  the 
characteristic  stigmata  of  the  disease,  the  temperature  re- 
mains normal,  and  careful  observation  will  usually  de- 
tect a  flaw  in  the  symptom  complex. 

Prognosis  of  Shock. 

This  depends  on  the  degree  of  the  injury,  the  severity 
of  the  symptoms,  the  general  condition  of  the  patient,  and 
the  presence  or  absence  of  complications  like  septic  in- 
fection. Shock  may  prove  instantly  fatal,  as  in  death 
from  a  blow  over  the  solar  plexus ;  or  the  patient  may 
live  one  or  two  days  and  finally  die ;  or  recovery  may 
take  place  when  hope  has  been  practically  abandoned. 
Shock,  the  result  of  profuse  hemorrhage,  is  more  dan- 
gerous than  shock  from  other  causes. 


221 


SURGICAL  SHOCK 


Treatment  of  Shock. 

While  much  difference  exists  among  surgeons  as  to 
the  treatment  of  shock  when  it  develops  there  is  great 
unanimity  of  opinion  as  to  the  necessity  of  using  certain 
measures  to  prevent  its  occurrence.  Shock  is  rarely 
seen  in  a  hospital  where  well-conducted  operations  are 
skillfully  performed  on  properly  prepared  patients.  The 
call  for  curative  treatment  of  shock  is  now  principally 
seen  in  cases  injured  in  railway  accidents  or  other 
catastrophes. 

Preventive  Treatment. 

I.  Avoid  fright  by  gaining  the  patient's  confidence,  in- 
spiring him  with  hope,  and  sending  him  to  the  operating 
room  in  good  mental  condition.  If  the  operation  be  one 
of  election,  the  surgeon  should  be  absolutely  frank  in  dis- 
cussing the  dangers  of  the  proceedure  at  the  time  the 
patient  is  considering  whether  or  not  to  have  it  done.  If, 
however,  it  is  decided  to  do  the  operation,  the  surgeon 
should  no  longer  refer  to  the  possibility  of  disaster  or 
death,  but  should  become  optimistic  and  dwell  on  the 
relief  and  benefits  to  be  expected.  If,  at  the  time  of  the 
operation,  the  patient  is  nervous,  it  is  often  wise  to  give  a 
hypodermic  of  morphine.  In  the  case  of  a  child,  when 
possible,  it  is  well  to  fix  the  hour  of  the  operation  so  that 
the  anesthetic  may  be  begun  while  the  patient  is  asleep. 

Sometimes  an  adult  is  met  with  who  is  so  panic- 
stricken  at  the  thought  of  an  operation  that  it  may  be 
necessary  to  adopt  the  following  method  suggested  by 
Crile,  which,  of  course,  should  only  be  carried  out  with 
the  full  consent  of  near  relatives  or  friends:  The  sur- 


SURGICAL  SHOCK 


geon  tells  the  patient  on  his  admission  to  the  hospital 
that  he  does  not  know  whether  or  not  it  will  be  necessary 
to  operate  on  him,  and  that  he  will  only  undertake  the 
case  with  the  distinct  agreement  that  he  is  to  do  what- 
ever he  thinks  best.  The  consent  of  the  patient  having 
been  obtained,  he  is  subjected  to  considerable  prelimi- 
nary examination,  and  linally  told  that  he  will  be  given 
the  'inhalation  treatment."  An  anaesthetizer  goes  to  the 
bed  at  a  certain  hour  each  day,  places  a  mask  over  his 
face  and  lets  him  inhale  alcohol,  disguised  with  some 
aromatic  agent.  At  the  same  hour  on  the  day  set  for  the 
operation  the  alcohol  is  given  as  usual,  with  the  slow 
addition  of  an  anesthetic,  until  unconsciousness  is  pro- 
duced and  the  patient  can  be  transported  to  the  operatmg 
room.  This  expedient  has,  in  Crile's  opinion,  enabled 
him  to  save  several  lives  which  would  otherwise  have 
been  lost. 

2.  Avoid  loss  of  blood  during  the  operation  by  the  use 
of  Esmarch's  bandages  and  constictors  in  amputations, 
by  angulation  of  the  table  in  work  on  the  head  and  neck, 
and  by  carefully  and  quickly  catching  and  tying  all  bleed- 
ing vessels.  Bloodgood  says  that  a  long  bloodless  opera- 
tion is  less  likely  to  produce  shock  than  a  short  bloody 
one. 

3.  Avoid  loss  of  heat  by  operating  in  a  warm  room, 
keeping  exposed  viscera  and  raw  surfaces  protected  with 
hot  moist  towels,  and  seeing  that  the  patient  does  not  be- 
come wet  with  solutions.  It  is  also  wise  not  to  have  the 
patient  in  actual  contact  with  the  surface  of  a  glass  or 
iron  table,  but  to  interpose  some  non-conductor,  if  not 
actually  to  put  him  on  a  hot-water  pad. 

4.  Avoid  loss  of  time,  not  by  breathless  haste,  which 

223 


SURGICAL  SHOCK 


might  lead  to  imperfect  work,  but  by  having  a  distinct 
plan  of  the  operation  in  mind  and  executing  its  various 
steps  speedily.  Occasionally,  in  extremely  difficult  and 
tedious  operations,  requiring  more  than  an  hour  for  their 
execution,  it  is  well,  if  circumstances  permit,  to  do  part 
of  the  work  one  .day  and  complete  it  one  or  two  days 
later.  Victor  Horsley  advocates  this  being  regularly  done 
in  cerebral  surgery,  trephining  and  exposing  the  dura  one 
day,  and  subsequently  dividing  it  and  doing  the  work  in 
the  brain  structure. 

5.  Avoid  bruising  and  tearing  tissue,  roughly  handling 
or  pulling  on  viscera.  Dissection  should  not  be  made 
bluntly,  and  all  manipulations  should  be  gently  carried 
out.  The  fact  that  the  patient  is  under  an  anaesthetic 
and  his  sensory  centers  unable  to  appreciate  pain  does 
not  mean  that  his  vaso-motor  and  cardiac  centers  are 
equally  protected  and  he  cannot  develop  shock. 

6.  Avoid  division  of  large  nerves,  especially  in  weak 
patients,  until  these  have  been  blocked  by  the  intra-neural 
injection  of  cocaine.  Crile  says:  ''As  no  impulses  of  any 
kind  can  pass  either  upward  or  downward,  there  is  no 
more  shock  in  dividing  tissues — even  the  nerve  trunks 
themselves,  thus  blocked — than  in  dividing  the  sleeve  of 
the  patient's  coat."  In  operations  on  the  lower  extremity 
and  pelvis  this  principle  can  be  more  extensively  applied 
by  injecting  the  cocaine  into  the  spinal  canal  at  or  near 
the  fourth  lumbar  vertebra. 

Curative  Treatment. 

When  shock  is  actually  present,  active  treatment  is  of 
little  use,  and  in  using  remedies  the  surgeon  should  be 
careful  that,  if  he  do  no  good,  at  least  he  do  no  harm. 

224 


SURGICAL  SHOCK 


Senn  says  that  it  is  as  important  to  know  what  not  to  do 
as  to  'know  what  to  do,  and  Warren  emphasizes  the  fact 
that  it  should  be  clearly  remembered  that  the  condition 
is  one  of  exhaustion,  and  rest  is  needed  for  repair.  As 
the  symptoms  of  shock  are  those  of  profound  weakness 
and  prostration,  it  was  long  a  practice  to  give  stimulants, 
such  as  alcohol,  digitalis  or  strychnine.  According  to  the 
modern  pathology,  which  is  undoubtedly  correct,  these 
remedies  do  harm.  The  centers  are  already  partly  or 
completely  paralyzed  from  over-stimulation,  and  the  ad- 
ministration of  strychnine,  according  to  Mummery,  "is 
like  beating  a  tired  horse — it  may  call  forth  an  effort  if 
we  beat  hard  enough,  but  it  hastens  the  end."  Or,  to 
quote  Crile,  **It  would  be  just  as  logical  to  treat  strych- 
nine poisoning  with  traumatic  shock  as  to  treat  trau- 
matic shock  with  strychnine." 

The  only  rational  remedy  would  be  one  which  would 
act  not  on  the  centers,  but  on  the  dilated  vessels,  restor- 
ing the  peripheral  resistance.  Unfortunately,  we  have 
no  satisfactory  means  to  accomplish  this  end.  The  fol- 
lowing is  a  brief  description  of  the  present  accepted  mode 
of  treatment : 

1.  Secure  physiological  rest  by  placing  the  patient  in 
a  quiet  room,  excluding  all  friends  and  relatives,  and 
giving  a  moderate  dose  of  morphine.  The  surgeon  and 
attendants  should  be  calm  and  confident  in  their  manner, 
and  the  patient  should  not  be  allowed  to  infer  that  his 
condition  is  unusual  or  alarming. 

2.  Apply  external  heat  by  placing  the  patient  between 
warm  blankets,  putting  hot-water  bags  to  the  feet,  thighs, 
and  body,  and  in  some  cases  injecting  hot  fluids  into  the 
rectum. 

225 


SURGICAL  SHOCK 


3.  Support  the  circulation  mechanically  by  posture,  by 
bandaging,  or  by  the  pneumatic  suit.  In  mild  cases  of 
shock  all  that  may  be  necessary  is  to  lower  the  head,  thus 
gravitating  the  blood  to  the  anemic  brain.  In  graver 
cases  the  limbs  should  be  enveloped  in  elastic,  non-ab- 
sorbent cotton,  and  firmly  bandaged  from  extremity  to 
body.  A  compress  may  also  be  applied  over  the  abdomen. 
Crile's  pneumatic  suit  is  an  appliance  by  which  the  entire 
surface  of  the  body  is  subjected  to  pressure  by  com- 
pressed air.  Unfortunately,  however,  it  is  rarely  at  hand 
when  needed. 

4.  Transfusion  with  warm  saline  solution  by  rectum, 
beneath  the  skin,  or  into  a  vein.  In  cases  of  shock  due 
to  hemorrhage  this  is  the  most  logical  and  efficient  method 
of  treatment.  In  cases  of  shock  from  other  causes,  how- 
ever, it  is  not  so  valuable.  The  average  individual  can 
only  take  up  about  two  quarts  of  the  solution.  After 
this  amount  has  been  given  an  interval  must  elapse,  and 
then  only  two  or  three  ounces  given  at  a  time.  If  this 
precaution  is  disregarded,  fatal  complications  may  ensue 
from  edema  of  the  pulmonary  or  abdominal  regions. 

5.  The  administration  of  adrenalin  chloride,  which  is 
usually  effected  by  combining  it  with  the  saline  solution 
used  in  transfusion,  one  drachm  of  the  i-iooo  commercial 
solution  being  added  to  one  quart  of  normal  salt  solution 
and  introduced  slowly,  but  continuously,  the  rate  regu- 
lated by  the  character  of  the  symptoms  or  the  record  of 
a  sphygmomanometer. 

Question  of  Operating  During  Shock. 

In  accident  cases  the  surgeon  is  confronted  with  the 
question  whether  to  operate  at  once  or  wait  for  reaction ; 

226 


SURGICAL  SHOCK 


whether  he  had  better  add  the  shock  of  an  operation  to 
the  shock  of  the  injury,  with  danger  of  death  of  the 
patient,  or  whether  he  had  better  wait,  hoping  for  im- 
provement, but  possibly  sacrificing  the  patient's  only 
chance  for  life.  There  is  no  rule,  although  most  authori- 
ties advise  waiting,  unless  the  mutilation  causes  great 
pain,  or  unless  hemorrhage  is  actually  in  existence.  On 
ihe  other  hand,  Wainwright  says:  "To  remove  the  nerve 
impulses  after  trauma  an  immediate  repair  of  injury  is 
very  important.  Leaving  a  mangled,  oozing  limb,  with 
crushed  and  exposed  nerves,  with  the  hope  that  it  will 
give  more  favorable  opportunity  for  intervention,  will, 
in  many  cases,  by  allowing  the  cause  continually  to  act, 
only  drive  the  patient  into  a  condition  beyond  all  hope." 


227 


Sulphate  of  Spartine  in  Surgical 
Practice  * 

Like  most  surgeons,  I  devote  little  time  to  the  study 
of  the  therapeutic  action  of  drugs.  Patients  who  are  re- 
ferred to  me  have  usually  exhausted  the  resources  of 
materia  medica,  and  in  my  practice  I  rarely  have  occasion 
to  employ  medicinal  agents  other  than  the  well-known 
anaesthetics,  antiseptics,  purgatives  and  tonics.  I  believe, 
however,  I  have  accidentally  discovered  in  sulphate  of 
spartine  a  valuable  remedy  for  the  prevention  and  treat- 
ment of  post-operative  suppression  of  urine. 

I  do  not  know  whether  or  not  my  experience  coincides 
with  that  of  other  surgeons,  but  it  is  a  fact  that  in  the 
last  five  years  I  have  lost  more  cases  from  post-operative 
suppression  of  urine  than  from  all  other  causes  com- 
bined, and  this  despite  the  almost  routine  use  of  chlro- 
form  as  an  anaesthetic. 

The  cases  have  usually  been  those  with  pre-existing 
nephritis  from  sepsis  or  cholemia.  Shock  has  not  ap- 
parently been  a  factor,  for  the  condition  would  not  de- 
velop for  twenty-four  or  thirty-six  hours.  A  patient 
operated  upon  for  retention  of  urine,  or  for  jaundice 
due  to  obstruction  of  the  common  duct,  would  do  well 
for  one  or  two  days,  and  just  as  he  was  thought  to  be 
out  of  danger,  there  would  come  the  news  that  he  was 
passing  no  urine.  He  would  become  restless,  then  list- 
less, would  develop  a  stupor  which  would  rapidly  deepen 


*  Read  before  the  Southern  Surgical  and  Gynecological  Asso- 
ciation,  December,   1906. 

229 


SULPHATE  OF  SPARTINE  IN 


into  coma,  and  would  die  with  all  the  symptoms  charac- 
teristic of  uremia.  In  the  treatment  of  this  condition  I 
tried  water  by  mouth,  under  the  skin  and  in  the  rectum ; 
hot  packs  and  vapor  baths;  cups  and  counter-irritants; 
strychnine,  digitalis  and  nitro-glycerin ;  calomel  and  saline 
purgatives ;  and  in  one  case  stripping  the  kidney  capsules, 
with  uniformly  bad  results. 

Two  years  ago  I  began  empirically  the  use  of  sulphate 
of  spartine,  and  now  I  have  the  record  of  six  cases  in 
which  I  am  sure  the  drug  was  the  means  of  saving  the 
patient's  life. 

I  will  not  occupy  the  time  of  the  Association  by  read- 
ing a  dissertation  on  spartine  which  I  would,  of  course, 
have  to  copy  from  a  text  book.  Its  therapeutic  effect 
is  to  increase  the  blood  pressure,  make  the  pulse  slower 
and  stronger,  and  act  as  a  powerful  diuretic.  Its  action 
is  manifest  in  thirty  minutes  after  administration  and 
lasts  for  four  to  six  hours. 

I  believe  the  reason  why  the  value  of  sulphate  of  spar- 
tine is  not  more  widely  recognized  is  because  authorities 
advise  its  use  in  doses  so  small  as  to  be  worthless.  To 
get  results,  it  must  be  given  hypodermatically  in  doses 
of  from  one  to  two  grains,  repeated  every  three  to  six 
hours.  When  so  employed,  I  have  repeatedly  seen  it 
pull  up  a  run-a-way  heart  and  set  in  motion  a  pair  of 
stalled  kidneys.  Its  use  should  not  be  delayed  until  sup- 
pression of  urine  is  already  in  existence,  but  it  should  be 
prescribed  as  a  prophylactic  as  well  as  a  curative  agent. 

I  do  not  mean  to  claim  that  it  is  specific,  or  that  it 
should  be  employed  to  the  exclusion  of  other  measures, 
such  as  purgatives,  transfusions  and   hot  packs.     I   do 


230 


SURGICAL  PRACTICE 


believe,  however,  from  actual  experience,  that  it  is  pre- 
ferable to  the  drugs  of  the  digitalis  type  in  rapidity  of 
action,  ease  of  administration,  and,  what  is  more  impor- 
tant— results. 


231 


The  After  Care  of  a  Surgical  Patient  * 

When  the  operation  is  concluded,  the  dressings  ap- 
plied, and  the  gown,  if  soiled  or  wet,  changed,  the  patient 
is  ready  to  be  taken  to  his  room.  To  accomplish  this 
would  seem  a  simple  procedure,  yet  from  the  lack  of 
definite  plan  it  is  often  the  occasion  of  much  confusion 
and  delay.  The  litter  consists  of  a  light  frame  of  metal 
tubing  resting  on  a  rolling  carriage.  The  frame  is  short 
enough  to  fit  lengthwise  in  the  patient's  bed.  The  litter 
is  covered  with  a  warm  dry  blanket.  It  is  rolled  up 
beside  the  operating  table.  Two  assistants  on  the  opposite 
side  of  the  table  now  lift  the  patient  vertically  upward 
while  two  others  slip  the  frame  beneath  him.  The  blanket 
worn  around  the  limbs  during  the  operation  is  now  re- 
moved and  the  blanket  on  the  litter  wrapped  about  him. 
The  frame  is  put  back  on  the  carriage  and  the  patient 
quickly  rolled  to  his  room.  The  frame  is  put  on  the  bed, 
the  patient  lifted  up  and  the  frame  slipped  out.  The 
transfer  is  complete  and  there  has  been  no  pulling  or 
hauling,  which  might  slip  a  ligature  or  disarrange  the 
dressings.  Some  one  must  now  sit  with  the  patient  until 
the  effects  of  the  anesthetic  have  worn  off  and  reaction 
has  taken  place. 

Shock  is  rarely  seen  in  an  alarming  degree  after  opera- 
tions on  properly  prepared  patients,  planned  and  executed 
so  as  to  avoid  unnecessary  loss  of  heat,  blood  and  time. 


*  Printed  in  the  Charlotte  Medical  Journal,  December,  1905. 

22,2, 


THE  AFTER-CARE  OF  A  SURGICAL  PATIENT 

It  is  frequently  seen,  however,  in  accident  cases  espe- 
cially if  there  has  been  hemorrhage  or  mutilation. 

The  operating  room  is  not  the  place  to  treat  shock. 
Only  in  rare  cases  should  intravenous  or  subcutaneous 
transfusion  be  practiced  while  the  patient  is  on  the  table. 
The  unavoidable  delay  in  the  operation,  the  danger  of 
infection  and  the  manipulations  of  unskilled  assistants 
which  attend  the  procedure,  render  it  more  productive  of 
harm  than  of  good.  All  that  should  usually  be  done  is 
to  give  a  hypodermic  of  a  small  dose  of  morphine  and 
bend  every  energy  to  the  rapid  completion  of  the  opera- 
tive work  and  the  early  removal  of  the  case  from  the 
table.  The  patient  should  be  put  to  bed  between  warm 
blankets.  Additional  heat  should  also  be  applied  by 
means  of  hot  water  bags,  due  precautions  being  observed 
to  prevent  accidental  burns.  The  foot  of  the  bed  should 
be  elevated  to  gravitate  blood  to  the  anemic  brain.  The 
half  empty  blood  vessels  should  be  filled  by  the  intro- 
duction into  the  system  of  as  much  normal  saline  solution 
as  it  will  take  up.  This  can  best  be  effected  by  low  press- 
ure continuous  rectal  injection.  By  this  method  many 
quarts  of  fluid  can  be  introduced  without  discomfort  or 
traumatism. 

While  the  use  of  small  doses  of  morphine  has  a  decided 
effect  for  good,  the  confidence  formerly  placed  in  strych- 
nine seems  misplaced.  If  shock  is  due  to  paralysis  of  the 
vaso-motor  system  then  stimulation  of  the  exhausted 
centers  will  result  in  more  harm  than  good.  Of  all  drugs 
employed  to  produce  re-action  the  solution  of  chloride  of 
adrenalin  seems  the  most  logical.  As  its  effect  is  evanes- 
cent the  dose  must  be  repeated  at  frequent  intervals. 
In  addition  to  the  measures  recommended  it  is  of  the 

234 


THE  AFTER-CARE  OF  A  SURGICAL  PATIENT 

utmost  importance  to  exclude  all  relatives  from  the  room, 
thus  removing  injurious  excitement.  The  patient  should 
not  be  encouraged  by  hysterical  reassurance,  but  made 
to  feel  that  everything  is  being  done  for  him  by  the  quiet 
self  confidence  exhibited  in  the  deportment  of  the  doctor 
and  nurses. 

Pain. — The  first,  and  to  the  patient,  the  most  important 
symptom  after  an  operation  to  demand  prompt  and  ade- 
quate treatment  is  pain.  It  is  often  a  difficult  question 
for  the  surgeon  to  decide  how  much  the  patient  really 
suffers,  and  what  measures  are  really  demanded.  Some 
patients  make  a  great  outcry  when  really  they  are  more 
scared  than  hurt,  and  the  pain  will  do  them  less  harm 
than  the  drug  which  brings  relief.  Again,  other  patients 
invested  with  a  sort  of  old  fashioned  doctrine  of  predesti- 
nation will  make  no  complaint,  and  it  is  only  by  seeing 
the  set  face,  the  compressed  lips  and  clinched  hands  and 
noting  the  cold  and  clammy  skin,  that  a  knowledge  is 
derived  of  the  necessity  for  giving  an  opiate.  When  pain 
is  moderate  the  patient  should  be  encouraged  to  bear  it, 
but  when  it  is  excessive  the  patient  should  be  relieved 
by  the  hypodermic  use  of  morphine.  The  bromides  and 
coal  tar  preparations  are  worse  than  useless.  Morphine 
in  small,  and  if  necessary  repeated  doses,  is  what  is  de- 
manded. It  is  true  the  drug  may  mask  symptoms,  cause 
nausea  and  produce  constipation,  but  it  is  the  lesser  horn 
of  the  dilemma.  In  the  old  days  morphine  was  first  abused, 
and  then  not  used.  Even  now  some  well  known  authori- 
ties decry  its  employment.  The  majority  of  modern  sur- 
geons, however,  believe  that  when  administered  judic- 
iously it  not  only  brings  temporary  relief,  but  frequently 
saves  life. 

235 


THE  AFTER-CARE  OF  A  SURGICAL  PATIENT 

Nausea. — Another  frequent  and  distressing  symptom 
from  which  the  patient  suffers  after  an  operation  is 
nausea  and  vomiting,  primarily  due  to  the  anesthetic,  but 
sometimes  continued  by  sepsis  and  the  presence  of  blood 
and  bile  in  the  stomach.  When  the  patient  retches  on 
the  operating  table,  and  it  is  evident  there  is  fluid  in  the 
stomach,  then  much  after  distress  will  be  avoided  if  the 
stomach  contents  are  washed  out  before  he  is  taken  to  his 
room.  This  procedure  is  a  routine  practice  with  some  sur- 
geons, but  is  not  necessary  or  advisable  in  all  cases.  When 
nausea  and  vomiting  continue  it  is  at  first  treated  ten- 
tatively by  putting  ice  cloths  to  the  forehead  and  throat, 
applying  a  mustard  plaster  to  the  pit  of  the  stomach,  and 
giving  cracked  ice  or  a  few  sips  of  water.  If  the  symp- 
toms are  unrelieved  the  patient  is  given  two  glasses  of 
tepid  water.  It  is  always  taken  with  relish.  If  retained 
it  reestablishes  peristalsis  in  the  proper  direction,  and 
if  rejected  it  washes  out  the  stomach  contents  almost  as 
effectually  as  could  be  done  by  lavage.  Drugs,  such  as 
creosote,  oxalate  of  cerium,  ingluvin,  bismuth,  hydro- 
cyanic acid,  etc.,  have  been  found  useless,  and  efferves- 
cent drinks  such  as  ginger  ale  and  champagne  are  inju- 
rious. In  the  vast  majority  of  cases  the  nausea  will  cease 
spontaneously  as  soon  as  the  chloroform  or  ether  is  elimi- 
nated from  the  blood.  Time  is  the  only  panacea  and 
unless  symptoms  of  danger  are  evident  the  less  that  is 
done  by  the  surgeon  the  sooner  the  patient  will  experience 
relief. 

In  a  few  cases  the  vomiting,  instead  of  getting  better, 
gets  worse.  At  first  the  patient  strains  violently  and 
ejects  a  clear  or  yellow  fluid.  Later  without  muscular 
effort  there  is  the  constant  regurgitation  of  a  green  or 

236 


THE  AFTER-CARE  OF  A  SURGICAL  PATIENT 

black  fluid.  There  is  little  or  no  nausea,  but  at  frequent 
intervals  the  patient  gives  a  little  gulp  and  spits  out  a 
mouthful  of  what  is  popularly  supposed  to  be  bile.  A 
chemical  examination  will  show  that  it  is  not  bile  but 
blood.  The  patholog}^  of  this  condition  is  a  disputed 
question,  but  it  is  generally  believed  that  a  low  grade  of 
septicemia  has  so  weakened  the  gastric  blood  vessels  as 
to  permit  the  hemorrhagic  transudation.  The  practical 
fact  is  that  if  these  patients  are  let  alone  most  of  them 
will  die.  The  introduction  of  a  stomach  tube  will  show 
the  presence  of  a  quart  or  more  of  black  fluid  in  the 
stomach.  What  is  spit  up  is  merely  the  overflow.  If 
the  material  remains  in  the  stomach  the  patient  may  die 
from  exhaustion.  If  the  material  passes  into  the  intes- 
tines the  patient  may  die  from  toxemia.  The  prompt  use 
of  the  stomach  tube  at  the  first  symptom  of  black  vomit, 
the  emptying  of  the  viscus  and  the  irrigation  of  its  cavity 
with  normal  saline  or  a  weak  adrenalin  solution  gives  the 
only  chance  for  life. 

Position  in  Bed. — In  the  early  days  of  abdominal  sur- 
gery patients  were  kept  on  their  backs  and  not  allowed 
to  turn  on  the  side  for  the  first  seven  days.  It  was  found, 
however,  that  in  addition  to  the  suffering  entailed  there 
was  an  increase  in  the  liability  to  complications.  After  an 
ovariotomy  or  hysterectomy  it  is  well  to  keep  the  patient 
in  one  position  for  the  first  twenty-four  hours  to  lessen 
the  danger  of  a  ligature  slipping,  but  in  operations  like 
appendicitis  the  patient  should  be  encouraged  to  lie  first 
on  one  side  and  then  on  the  other.  In  cases  of  opera- 
tions on  the  stomach  or  where  there  is  a  vaginal  drain, 
the  patient  should  be  put  in  an  exaggerated  Fowler's 
position  in  order  to  carry  fluids  in  the  desired  direction 

237 


THE  AFTER-CARE  OF  A  SURGICAL  PATIENT 

by  gravity.  Some  surgeons  go  so  far  as  to  put  all  lapa- 
rotomies in  a  sitting  position  from  the  first,  claiming  not 
only  better  drainage,  but  increased  freedom  of  respira- 
tion from  the  removal  of  the  pressure  of  the  liver  on 
the  diaphragm.  The  position  of  the  patient  in  bed  is  one 
of  the  essential  features  of  the  Fowler-Murphy  method  of 
treating  cases  of  diffuse  peritonitis,  hence  hospitals 
should  have  facilities  and  nurses  experience,  to  enable 
them  to  handle  such  cases. 

Bladder  and  Kidneys. — During  the  first  few  days  after 
an  operation  the  bladder  and  kidneys  require  careful 
watching  to  see  that  they  properly  perform  their  func- 
tions. If  the  patient  does  not  voluntarily  pass  urine  he 
should  be  urged  to  make  every  effort  to  do  so.  A  cathe- 
ter should  not  be  employed  if  it  is  possible  to  avoid  it,  as 
its  use  always  entails  some  danger  of  infection,  and  makes 
the  patient  more  or  less  dependent  on  it  in  future.  Some- 
times, however,  it  has  to  be  employed  to  prevent  undue 
distention  of  the  bladder.  The  quantity  of  urine  should 
be  carefully  recorded  and  if  any  abnormality  is  noted  a 
specimen  should  be  sent  to  the  laboratory  for  examination. 

In  cases  of  chronic  interstitial  nephritis  and  in  cases 
of  acute  septicemia  and  cholemia  there  is  often  sudden 
suppression  of  urine  which  may  result  in  death.  After 
operations  on  patients  with  jaundice  more  cases  die  from 
uremia  than  from  any  other  one  cause.  At  St.  Luke's 
Hospital  the  old  treatment  of  transfusion,  sweating,  cups 
over  the  kidneys,  administration  of  infusion  of  digitalis, 
etc.,  has  given  very  poor  results.  Recently  a  new  line 
has  been  followed,  and  while  the  number  of  cases  is  yet 
too  few  to  justify  an  unqualified  statement,  still  it  is  be- 
lieved that  a  distinct  improvement  has  been  made.     As 

238 


THE  AFTER-CARE  OF  A  SURGICAL  PATIENT 

soon  as  any  inadequacy  of  kidney  activity  is  noted  sul- 
phate of  spartine  is  given  hypodermically  in  one  to  two 
grain  doses;  repeated  according  to  effects  at  four  or  six 
hour  intervals.  In  six  cases  where  there  w^as  complete 
suppression  there  has  been  prompt  response  to  the  drug, 
with  ultimate  recovery. 

Bowels. — When  peritonitis,  either  local  or  general,  was 
more  the  rule  than  the  exception  after  abdominal  sec- 
tions, it  was  the  practice  to  give  calomel  in  large  doses 
as  soon  as  the  stomach  w^ould  retain  it.  In  fact  the  sur- 
geon was  not  happy  until  the  patient  was  freely  purged. 

That  early  purgation  is  a  prophylactic  against  inflam- 
matory conditions  is  undeniably  true,  but  that  it  depletes 
the  patient,  retards  recovery,  and  is  not  necessary  under 
modern  methods  has  been  proved  to  the  satisfaction  of 
most  operators.  In  a  case  which  runs  smoothly,  in  other 
words  when  the  abdomen  is  not  distended  and  the  pulse 
and  temperature  are  practically  normal,  there  is  no  hurry 
to  purge.  Usually  a  soap  suds  enema  is  given  36  or  48 
hours  after  the  operation  and  the  bowels  afterwards  regu- 
lated if  necessary  by  the  administration  of  some  mild 
laxative  such  as  cascara  or  senna.  Occasionally,  how- 
ever, symptoms  quickly  develop 'which  forbode  evil,  and 
then  broken  doses  of  calomel  should  be  at  once  prescribed. 
Should  the  drug  be  rejected,  or  fail  to  act,  it  should  be 
followed  by  enemata.  When  the  abdomen  becomes 
swollen  and  tympanitic  the  administration  of  purgatives 
by  the  mouth  should  be  withheld.  The  bowels  are  paraly- 
tic from  distention,  and  stimulation  is  ineffective  and 
harmful.  In  this  condition  enemata  are  the  sole  reliance. 
Many  authorities  recommend  high  injections  through  a 
long  rectal  tube,  but  this  method  has  not  given  the  results 

239 


THE  AFTER-CARE  OF  A  SURGICAL  PATIENT 

that  were  claimed  for  it.  In  the  hands  of  the  average 
nurse  the  tube  simply  coils  up  in  the  rectum,  and  the 
surgeon  himself  usually  fails  in  his  efforts  to  pass  it 
through  the  sigmoid  flexure.  Fortunately  the  elevation 
of  the  hips  on  pillows  and  the  slow  injection  into  the 
rectum  with  an  ordinary  syringe  gives  about  as  good  re- 
sults, and  does  not  entail  as  much  manipulation  or  cause 
as  much  discomfort.  The  formula  of  the  enemata  used 
varies,  the  most  common  combination  consisting  of  gly- 
cerine, turpentine,  sulphate  of  magnesia  and  water.  Har- 
don,  of  Atlanta,  is  enthusiastic  in  advocating  a  mixture 
of  one  ounce  of  powdered  alum  to  one  quart  of  water, 
and  at  St.  Luke's  Hospital  human  bile  is  sometimes  used 
with  good  effect.  This  is  only  possible  when  a  case  of 
gall-bladder  drainage  is  in  the  house  to  supply  the  needed 
material.  For  the  past  ten  years  efforts  have  been  made 
by  many  experimenters  to  find  a  drug  which  would  pro- 
duce purgation  when  administered  hypodermically,  but 
so  far  without  success.  If  such  an  agent  is  ever  dis- 
covered it  will  prove  one  of  the  most  valuable  additions 
that  could  be  made  to  our  present  resources. 

Water. — As  an  empty  stomach  is  one  of  the  best  safe- 
guards against  vomiting,  water  should  be  withheld  from  a 
patient  for  several  hours  after  recovery  from  anesthesia. 
If  at  the  end  of  this  time  no  nausea  exists  it  may  be  given 
in  small  quantities  at  half  hour  intervals,  and  if  it  be 
well  borne  by  the  stomach  the  quantity  increased  until 
thirst  is  relieved.  The  water  may  be  acidulated  with 
lemon  juice,  or  cold  or  hot  tea  without  sweetening  sub- 
stituted for  it.  Should  vomiting  prevent  the  patient  from 
retaining  fluid,  thirst  may  be  relieved  by  allowing  the 
patient  to  rinse  out  the  mouth  with  water  to  get  the  taste, 

240 


THE  AFTER-CARE  OF  A  SURGICAL  PATIENT 

and  injecting  a  pint  of  saline  solution  in  the  rectum  to 
produce  the  effect. 

Nourishment. — If  the  patient  is  very  weak  nutritive 
enemata  may  be  used  from  the  first.  In  employing  this 
method  of  feeding  it  must  be  remembered  that  while  the 
rectum  can  absorb  it  cannot  digest,  hence  nutriment  must 
be  in  an  assimilable  form.  As  good  a  mixture  as  any  other 
consists  of  two  ounces  of  Peptohoids  or  Predigested  Beef 
and  four  ounces  of  saline  solution.  If  deemed  necessary 
one  ounce  of  whiskey  may  be  added.  Nutritive  enemata 
should  not  be  given  oftener  than  every  six  hours,  and 
the  rectum  should  be  irrigated  once  daily  to  remove  resi- 
duum or  other  irritating  material.  The  average  patient 
does  not  require  any  nourishment  for  the  first  twenty- 
four  or  thirty-six  hours.  In  fact  many  may  safely  and 
advantageously  be  allowed  to  go  without  food  for  two 
or  three  days.  Dr.  Tanner  has  taught  the  profession 
that  starvation  is  not  an  immediate  danger.  The  case, 
whose  death  is  attributed  to  exhaustion,  usually  dies 
of  some  form  of  sepsis. 

The  first  nourishment  given  a  patient  by  mouth  should 
be  liquid,  easily  digested  and  not  likely  to  cause  gas 
in  the  stomach  and  intestines.  Egg  albumen,  chicken 
broth,  beef  tea  and  buttermilk  fulfill  these  conditions. 
After  the  third  day,  if  everything  is  going  well,  soft 
boiled  eggs,  milk  toast  and  other  semi-solid  articles  of 
diet  may  be  added.  At  the  end  of  the  first  week  the 
patient  may  be  allowed  the  ordinary  hospital  bill  of  fare. 

Tonics. — But  little  medicine  as  a  rule  is  given  in  a  sur- 
gical hospital.  If  the  patient's  appetite  flags  a  table- 
spoonful  of  whiskey  before  meals  or  a  glass  of  wine  or 
beer  with  meals  is  usually  more  productive  of   results 

241 


THE  AFTER-CARE  OF  A  SURGICAL  PATIENT 

than  distasteful  drugs.  If  the  patient  feels  he  is  being 
neglected  he  should  be  given  tincture  of  nux  vomica  or 
some  harmless  placebo,  with  which  the  market  is  well 
supplied. 

General  Hygiene. — The  efficiency  of  the  modem 
trained  nurse  leaves  but  little  for  the  surgeon  to  suggest 
in  regard  to  changing  bed  linen,  giving  baths,  rubbing 
the  back,  etc.  If  there  is  one  point  occasionally  neglected 
it  is  the  toilet  of  the  mouth.  The  proper  use  of  the  tooth 
brush  and  the  employment  of  antiseptic  washes  will  not 
only  add  to  the  patient's  comfort,  but  prevent  fermen- 
tation of  food  by  the  reduction  in  the  number  of  bacteria 
taken  into  the  digestive  tract. 

Length  of  Confinement  to  Bed. — It  is  of  course  im- 
possible to  have  any  hard  and  fast  rule  as  to  how  long 
it  is  necessary  to  keep  a  patient  in  bed  after  an  operation. 
Each  case  must  be  considered  on  its  special  indications. 
A  prudent  patient  may  be  allowed  to  sit  up  sooner  than 
a  reckless  one.  A  lean  individual  will  secure  a  firm 
cicatrix  quicker  than  a  fat  one.  A  wound  that  unites 
by  primary  intention  does  not  necessitate  the  same  length 
of  confinment  as  one  that  suppurates.  Still  there  ought 
to  be  some  consensus  of  opinion  among  surgeons  of  ex- 
perience as  to  how  long  an  uncomplicated  abdominal  case 
should  retain  the  recumbent  position.  Unfortunately 
the  beginner  who  consults  literature  for  the  answer  to 
this  question  will  find  the  expression  of  very  dififerent 
views.  Some  surgeons  put  their  appendicitis  cases  up 
on  the  seventh  day  and  send  them  home  on  the  ninth. 
Others  keep  them  in  bed  three  or  four  weeks  and  dis- 
charge them,  with  many  injunctions  as  to  prudence,  a 
week  or  ten  days  later.     The  tendency  is  to  make  the 

242 


THE  AFTER-CARE  OF  A  SURGICAL  PATIENT 

patient's  stay  in  the  hospital  shorter  and  shorter.  This 
is  partly  due  to  improved  results,  but  also  influenced  by 
a  desire  to  advertise  the  surgeon,  to  make  the  patient 
more  willing  to  consent  to  an  operation,  to  increase  the 
number  of  cases  cared  for  by  a  ward  of  limited  capacity, 
and  finally  to  lessen  the  money  paid  to  the  hospital  so 
there  may  be  more  left  for  professional  services.  Be- 
tween too  great  conservatism  on  the  one  hand,  with  the 
attendant  loss  of  time  and  money,  and  too  great  radi- 
calism on  the  other,  with  the  danger  of  hernia  and  other 
complications,  there  must  eventually  be  derived  the  happy 
mean.  At  present  the  average  surgeon  keeps  an  appendi- 
citis case  in  bed  about  two  weeks  and  discharges  him  in 
three.  An  operation  necessitating  greater  weakening  of 
the  abdominal  wall  such  as  a  hysterectomy  confines  the 
patient  to  bed  three  weeks  and  to  the  hospital  four.  Ex- 
perience has  proved  that  incisions  in  the  upper  abdomen, 
for  liver  and  stomach  work,  do  not  entail  the  same  lia- 
bility to  hernia  as  openings  in  the  lower  abdomen  for 
pelvic  tumors,  hence  the  time  in  bed  after  the  former 
may  safely  be  less  than  after  the  latter.  The  use  of 
abdominal  belts  after  operations  is  not  advisable  unless 
the  abdomen  is  pendulous,  or  in  cases  where  the  cicatrix 
is  weak  owing  to  the  employment  of  drainage.  This  last 
indication  for  the  use  of  an  irksome  prophylactic  measure 
has  been  materially  lessened  by  the  present  practice  of 
inserting  drains,  when  needed,  through  stab  incisions  and 
closing  the  operative  wound  as  if  no  drain  had  been 
employed. 

The  After  Care  of  Wounds. — Clean  wounds,  without 
drainage,  need  not  usually  be  dressed  until  the  eighth 
or  ninth  day,  when  the  stitches  are  removed  and  a  second 

243 


THE  AFTER-CARE  OF  A  SURGICAL  PATIENT 

dressing  applied.  The  three  indications  for  an  earlier 
dressing  are  pain,  fever,  or  saturation  of  dressings  with 
wound  secretion.  Should  the  wound  be  uncomfortable 
when  there  is  no  rise  of  temperature  it  is  probably  due 
to  stiffening  of  the  dressings  with  blood  or  serum,  and 
redressing  will  give  immediate  relief.  Should  there  be 
a  tight  stitch  with  a  read  area  about  it,  it  should  be 
clipped  or  removed  as  soon  as  discovered  in  order  to 
prevent  the  formation  of  an  abcess. 


244 


Past,    Present   and   Future   of  Cancer  * 

Cancer  has  been  a  constant  subject  of  study  in  all  ages 
and  in  all  nations;  but  the  mystery  of  its  origin  has  yet 
been  unsolved,  resistance  to  its  progress  has  yet  proved 
unsuccessful,  and  the  symbolic  crab  continues  to  sink  its 
claws  slowly  but  relentlessly  into  the  flesh  of  its  victim. 
The  disease,  at  first  local,  becomes  regional  and  consti- 
tutional, recurring  when  removed,  disseminating  when 
left ;  undergoing  degeneration,  intractable  ulceration,  deep 
spreading  excavation,  and  is  usually  followed  by  cachexia 
and  death. 

It  is  the  object  of  this  paper  to  review  the  history  of 
cancer,  to  call  attention  to  the  recent  view^s  of  the  etiology 
of  the  disease,  to  state  the  present  accepted  principles 
of  its  treatment,  and  to  suggest  the  possible  developments 
of  the  future — a  scope  admittedly  too  broad  to  be  prop- 
erly covered  in  the  time  at  the  writer's  disposal  for  prep- 
aration, or  of  the  Society's  programme  for  reading. 

History  and  Etiology  of  Cancer. 
The  earliest  medical  writings  contained  descriptions  of 
tumors,  and  their  origin  was  attributed  to  the  influence 
of  maHgn  or  evil  spirits.  Hippocrates  taught  that  the 
body  was  composed  of  four  humors — blood,  phlegm,  black 
bile  and  yellow  bile;  and  Galen  believed  that  tumors  re- 
sulted from  the  accumulation  of  one  of  these  humors. 
Harvey,  by  the  discovery  of  the  circulation  of  the  blood, 


*  Read  at  a  meeting  of  the  Medical  Society  of  Virginia,  Lynch- 
burg, Va.,  November,   1901. 

245 


THE    PAST,   PRESENT   AND 


overturned  preconceived  views  of  pathology,  and  the 
blood  was  next  regarded  as  the  source  of  disease,  and  its 
organization  the  origin  of  tumor  formation.  Boerhaave, 
some  years  later,  ascribed  tumors  to  the  newly  discovered 
lymph,  the  vitiated  or  degenerated  variety  being  supposed 
to  produce  cancer.  Hunter  was  the  first  to  recognize  the 
similarity  in  structure  between  tumors  and  normal  tis- 
sues, and  to  maintain  that  they  originated  by  a  modifi- 
cation of  formative  processes.  Broussais,  early  in  the 
nineteenth  century,  claimed  that  all  tumors,  including 
cancer,  were  forms  of  chronic  inflammation  consequent  on 
organic  irritation.  This  view,  owing  to  its  simplicity 
and  comprehensiveness,  at  once  became  accepted,  but  its 
supremacy  was  short-lived.  Schleiden,  with  the  aid  of 
the  then  recently-perfected  microscope,  discovered  the 
cellular  structure  of  plants.  Schwann  demonstrated  the 
analogy  in  animals;  Muller  established  the  fact  that  tu- 
mors were  formed  of  cells,  but  believed  the  cells  were 
derived  from  the  blood.  Virchow  accepted  the  cellular 
structure  of  tumors,  but  denied  the  blastodermal  origin  of 
the  cells.  He  proved  that  cells  could  not  develop  de  novo, 
but  followed  biological  laws,  and  were  always  the  result 
of  the  division  of  pre-existing  cells.  He  believed  in  meta- 
plasia, and  taught  that  a  given  cell  under  some  conditions 
might  become  an  epithelial  cell,  and,  under  other  condi- 
tions, a  connective  tissue  cell.  Cohnheim  controverted 
the  existence  of  metaplasia,  and  established  the  law  of 
the  legitimate  succession  of  cells.  He  classified  tumors 
by  referring  each  to  the  embryonic  layer,  from  which 
its  cell  had  origin,  and  advanced  a  novel  and  ingenious 
theory  to  explain  their  development.  He  claimed  that 
during  the  progress  of  cell  diflferentiation  in  the  embryo 

246 


FUTURE   OF    CANCER 


more  cells  were  produced  at  a  certain  point  than  were 
necessary  for  the  formation  of  that  particular  region. 
He  believed  that  these  left-over  cells — not  utilized  by 
the  growth  of  the  organism — were  arrested  in  their  fur- 
ther development  and  remained  in  a  dormant  condition. 
He  claimed  that  if  the  energy  of  these  detached  and 
slumbering  islets  of  embryonal  cells  were  reawakened 
later  by  internal  or  external  stimulation,  they  would 
undergo  rapid  proliferation  and  form  a  tumor,  whose 
histologic  type  and  clinical  behavior  would  depend  on  the 
epiblastic,  mesoblastic,  or  hypoblastic  source  of  the  parent 
cells.  The  physiologic  analogue  of  this  hypothetic  patho- 
logic process  is  seen  in  the  changes  which  occur  in  the 
human  body  at  the  age  of  puberty,  when  cells  that  have 
slept  for  years  with  latent  energy  are  re-awakened,  and, 
multiplying  rapidly,  produce  the  development  of  the  sex- 
ual organs  and  the  other  changes  characteristic  of  that 
period. 

Based  on  Cohnheim's  theory,  which  is  almost  univer- 
sally accepted,  the  term  tumor  is  now  used  in  a  much 
more  restricted  sense  than  formerly.  At  one  time  the 
word  was  employed  to  designate  all  kinds  of  swellings ; 
now  a  sharp  line  of  separation  is  drawn  between  tumors 
supposed  to  be  the  result  of  the  proliferation  of  embryo- 
nal cells  occurring  independently  of  microbic  cause,  and 
inflammatory  swellings  demonstrated  to  be  the  result  of 
the  proliferation  of  mature  cells  produced  by  the  action 
of  pathogenic  organisms. 

Bacteriologists  have  accepted  this  division,  but  have 
patiently  and  persistently  endeavored  to  prove  that  many 
of  the  growths  supposed  to  be  tumors  or  neoplasms,  due 
to  the  proliferation  of  embryonal  cells,  were  really  in- 

247 


THE    PAST,    PRESENT    AND 


flammatory  swellings,  due  to  the  action  of  hitherto  un- 
known but  recently-discovered  micro-organisms. 

In  the  past  few  years  lupus,  syphilis,  leprosy,  tuber- 
culosis, actinomycocis,  and  other  diseases  have  been 
proved  either  by  direct  demonstration  or  by  argument 
from  analogy,  to  be  due  to  a  germ,  and  one  by  one  have 
been  transferred  from  the  slowly  diminishing  list  of  tu- 
mors to  the  gradually  increasing  list  of  infective  gran- 
ulomata.  At  this  time  a  vigorous  and  well-directed  effort 
is  being  made  to  prove  that  cancer  is  due  to  a  parasite, 
but  the  claim  is  resisted  by  the  adherents  of  the  cellular 
theory  of  the  origin  of  the  growth.  Two  papers  read 
a  few  months  ago  at  the  same  meeting  of  the  American 
Medical  Association,  one  by  Dr.  Nicholas  Senn,  of  Chi- 
cago, and  the  other  by  Dr.  Rosewell  Park,  of  Buffalo, 
ably  and  forcibly  present  the  two  sides  of  the  question. 

Senn,  perhaps,  the  greatest  surgical  philosopher  of  the 
day,  presents  his  views  with  citations  of  authorities  so 
voluminous  that  while  the  article  will  remain  as  a  per- 
manent encyclopedia  of  reference  to  the  literature  of 
the  subject,  it  is  almost  impossible  to  make  an  abstract 
of  it  that  does  justice  to  the  author.  Senn  adheres  to  the 
cellular  theory  of  the  origin  of  cancer  and  claims  that 
from  an  etiologic  standpoint  very  little  has  been  added 
to  our  knowledge  of  the  disease  since  the  epoch-making 
labors  of  Virchow,  Cohnheim,  and  Waldeyer.  He  says 
that  after  the  demonstration  of  the  fact  that  all  inflam- 
matory processes  were  caused  by  micro-organisms,  it 
was  natural  that  by  reasoning  from  analogy  the  con- 
clusion was  reached  that  cancer  was  also  a  parasitic  dis- 
ease. Earnest  workers  in  all  parts  of  the  civilized  world 
have  investigated  the  subject;  various  methods  of  tissue 

248 


FUTURE   OF    CANCER 


staining,  cultivation,  and  inoculation  have  been  utilized ; 
numerous  intra-cellular  and  extra-cellular  bodies  have 
been  discovered  and  described;  but  the  numerous  claims 
of  having  isolated  the  essential  cause  of  cancer  have 
never  yet  been  substantiated.  Searching  criticisms  from 
different  reliable  sources  have  shown  almost  conclusively 
that  these  bodies  are  not  living  organisms,  but  the  pro- 
ducts of  degeneration  of  the  cell  protoplasm  of  a  non- 
parasitic nature. 

Senn  claims  that  the  histology  and  histogenesis  of  can- 
cer speak  against  a  parasitic  origin  of  the  disease,  be- 
cause of  the  difference  in  the  histologic  structure  of  the 
cells  which  constitute  the  mass  in  carcinoma  and  in  in- 
flammatory products.  Carcinoma  differs  morphologically 
according  to  the  structures  in  which  it  originates,  while 
inflammatory  products  present  the  same  structure  inde- 
pendent of  their  anatomic  location  or  character  of  the 
tissue  involved.  In  other  words,  carcinoma  of  the  breast 
when  transported  by  metastasis  to  the  liver  produces 
typical  breast  cancer  in  the  liver,  while  inflammation  of 
the  breast  transported  to  the  liver  produces  ordinary 
hepatitis. 

Senn  states  that  the  results  of  implanation  and  inocula- 
tion experiments  have  so  far  failed  in  establishing  the 
parasitic  theory  of  carcinoma.  The  two  objections  to  the 
validity  of  the  claim  are: 

1st.  The  variety  of  microbes  and  bodies  which  have 
been  found  in  carcinoma  tissue  by  different  experimenters 
and  for  all  of  which — at  different  times  and  by  different 
authors — the  same  specific  pathogenic  qualities  have  been 
claimed. 

2d.  The  histologic  structure  of  the  products  of  im- 

249 


THE   PAST,   PRESENT   AND 


planation  of  carcinoma  tissue — or  inoculation  with  the 
supposed  cancer  germs — does  not  correspond  with  the 
structure  of  a  true  carcinoma. 

Senn  states  that  no  well-authenticated  case  of  inocu- 
lation carcinoma  has  occurred  among  surgeons  who  have 
frequently  injured  their  fingers  and  hands  during  opera- 
tions for  carcinoma,  while  inoculation  tuberculosis  from 
the  same  cause  has  been  frequently  observed.  The  same 
can  be  said  of  persons  who  take  care  of  carcinoma  pa- 
tients, or  who  live  in  the  same  room  with  them.  In  the 
case  of  an  inoperable  carcinoma  of  the  leg,  Senn  im- 
planted subcutaneously  fragments  of  aseptic  carcinoma 
tissue  at  two  points  on  the  affected  limb.  During  the 
first  two  weeks  little  nodules  formed  at  the  point  of 
inoculation,  but  then  gradually  disappeared. 

On  May  4,  1901,  Senn  inoculated  himself  with  car- 
cinoma tissue  immediately  after  he  had  completed  a  radi- 
cal operation  for  advanced  carcinoma  of  the  lower  lip.  The 
patient  from  whom  the  malignant  graft  was  obtained  was 
an  Irishman  sixty  years  of  age.  The  submental  and 
submaxillary  lymphatic  glands  were  involved.  The  glands 
were  immersed  in  warm  saline  solutions,  and  from  one 
of  them  a  fragment  the  size  of  a  split  pea  was  used  for 
implantation.  A  small  incision  was  made  about  the  mid- 
dle of  the  forearm,  under  strict  aseptic  precautions.  One 
of  the  margins  of  the  wound  was  undermined  sufficiently 
to  make  a  pocket  large  enough  to  receive  the  graft.  After 
implantation,  the  wound  was  closed  with  a  horse-hair 
suture  and  iodoform  collodion.  The  carcinomatous  na- 
ture of  the  glandular  affection  was  proved  by  micro- 
scopic examination  of  the  gland  from  which  the  graft 
was  taken.     In  the  course  of  a  week  a  nodule  the  size 

250 


FUTURE   OF    CANCER 


of  a  pea  made  its  appearance,  which  remained  stationary 
for  two  weeks,  and  then  gradually  disappeared. 

Dr.  Roswell  Park,  to  whose  enthusiasm  and  inde- 
fatigable industry  was  due  the  establishment  of  the  New 
York  State  Pathological  Laboratory  for  the  Study  of 
Cancer,  takes  the  opposite  view.  He  claims  that  the 
infectiousness  of  cancer  has  been  proved,  but  admits 
that  the  exact  nature  of  the  organism  has  not  been  demon- 
strated. He  says  that  it  is  not  now  believed  that  cancer 
is  due  to  a  bacterium,  but  to  a  parasite,  perhaps  similar 
to  the  Plasmodium  of  malaria.  Little  is  known  of  these 
lowly  forms  of  animal  life,  and  it  has  not  yet  been  de- 
termined whether  Koch's  laws  for  the  determination  of 
the  infectious  nature  of  a  given  disease  are  valid  when 
applied  to  them.  In  the  Buffalo  Laboratory,  these  organ- 
isms have  been  found  whenever  conditions  were  favor- 
able, and  the  introduction  of  cultures  made  from  them 
has  produced  fatal  results  in  animals,  although  the  inocu- 
lations have  not  invariably  produced  distinct  carcinomata. 
Park  states  that  Cohnheim's  theory  explains  the  presence 
of  certain  cells  in  unusual  localities,  but  offers  nothing 
to  explain  the  peculiar  behavior  of  these  cells,  which 
constitute  the  essential  feature  of  malignant  growth.  He 
claims  that  the  parasitic  theory  is  much  more  satisfac- 
tory than  the  cellular  theory,  and  substantiates  his  views 
with  arguments  by  analogy,  by  comparative  pathology, 
by  miscroscopic  findings,  and  by  clinical  obsen^ations. 
He  states  that  the  study  of  tumor  formations  in  the 
vegetable  kingdom  shows  a  striking  analogy  between  the 
proposed  parasitic  theory  of  the  origin  of  cancer  in  ani- 
mals and  the  known  relation  of  insect  infection  in  plants. 
Botanists  have  shown  that  tumors  occur  in  trees.     They 

251 


THE    PAST,    PRESENT    AND 


vary  in  size  from  a  trifling  gall  to  a  large  woody  mass, 
and  are  frequently  spoken  of  as  "tree  cancers."  The 
infectious  agent  or  parasite  is  a  minute  insect,  which  dis- 
turbs cell  growth  and  produces  cell  proliferation.  Usually 
there  is  a  traumatism  of  the  bark  with  infection  of  the 
growing  wood  beneath.  A  combination  of  etiologic 
factors  is  necessary — the  infection  atrium  and  the 
infectious  agent.  Without  the  atrium  the  insect  could 
not  enter;  without  the  agent  the  breach  would  be  healed 
without  pathologic  change. 

Park  states  that  the  comparative  pathology  of  tumor 
formations  in  the  lower  animals  furnishes  an  equally 
strong  argument  in  favor  of  the  parasitic  theory  of  can- 
cer in  the  human  race.  Various  tumors  occurring  in  in- 
sects and  invertebrates  have  been  demonstrated  to  be 
due  to  protoza.  The  higher  we  go  in  the  animal  scale 
the  more  closely  do  these  tumors  resemble  those  in  the 
human  being,  until  the  histologic  characteristics  are  almost 
exactly  similar.  One  cannot  avoid  the  conclusion  that 
tumors  in  animals  and  man  are  due  to  the  same  general 
cause.  If,  then,  their  existence  in  animals  can  be  proved 
to  be  of  parasitic  origin,  it  strengthens  the  conclusion  in 
favor  of  a  similar  origin  for  such  lesions  in  man. 

Park  states  that  metastasis  is  regarded  as  the  principal 
evidence  of  infectiousness  in  all  infective  diseases — from 
the  most  acute  of  the  septic  and  pyemic  type  to  the  slower 
manifestations  of  tuberculosis.  The  similar  manifes- 
tion  in  cancer  is  a  like  evidence  of  its  infectious- 
ness; if  it  means  anything  in  the  one  case,  it  has  exactly 
the  same  meaning  in  the  other.  As  the  surgeon  watches 
a  case  of  melanotic  sarcoma  of  the  leg  and  sees  the 
gradual   transmission  of  the  disease  up  the  limb,  and 

252 


FUTURE   OF    CANCER 


becomes  still  later  aware  of  the  involvement  of  the  liver, 
then  of  the  lungs,  and  then  of  the  various  other  parts  of 
the  body,  how  can  he  help  but  say  that  this  is  a  disease 
which  travels  along  the  same  paths  and  after  the  same 
fashion  as  does  tuberculosis ;  or,  when  he  sees  cancer  eji 
ciiirasse  following  an  operation  for  cancer  of  the  breast, 
how  can  he  avoid  the  conviction  that  he  has  here  to  deal 
with  a  slowly  creeping  infection  which  is  gradually  ex- 
tending and  travelling  as  only  an  infection  can? 

On  the  microscopic  appearance  of  cancer,  Park  says 
that  it  is  a  well-known  fact  that  in  and  between  cells  of 
cancer  growth  are  seen  peculiar  forms  or  particles,  which 
have  been  regarded  by  some  as  parasites,  by  others  as 
a  product  of  cell  degeneration.  No  such  appearances  are 
noted  in  healthy  tissue,  or  in  the  infectious  granulomata, 
or  in  the  truly  benign  tumors.  They  must  be  either  cell 
degenerations  or  parasites.  Exactly  similar  appearances 
have  been  produced  in  large  numbers  after  inoculation 
with  cancer  material,  but  no  one  has  been  able  to  produce 
such  degenerations  under  other  circumstances. 

Under  clinical  observations  confirmatory  to  the  para- 
sitic theory  of  the  cause  of  cancer.  Park  reports  the  case 
of  a  woman  with  epithelioma  of  the  chest  wall  following 
a  burn.  As  a  result  of  the  cicatrix  her  arm  was  bound 
down  to  her  side,  and  a  cancerous  ulcer  appeared  on  its 
under  surface.  He  states  that  numerous  instances  in 
which  cancerous  infection  has  followed  the  track  of  in- 
struments, such  as  the  trocar,  afford  other  evidence  whose 
value  is  undeniable.  In  regard  to  the  objection  raised  to 
the  infectiousness  of  cancer,  based  on  the  fact  of  the 
almost  constant  failure  of  investigators  to  reproduce  the 
disease  by  inoculation  or  implantation,  he  says  that  the 

253 


THE    PAST,    PRESENT    AND 


failures  were  due  to  ignorance  in  regard  to  the  condi- 
tions which  favor  the  life  of  minute  organisms.  By 
observing  certain  conditions  at  the  Buffalo  Laboratory, 
carcinoma  has  been  produced  in  a  number  of  animals 
by  inoculation,  and  one  positive  demonstration  of  the 
infectiousness  of  the  disease  is  worth  more  than  one 
hundred  negative  experiments. 

Leaving  the  discussion  of  the  essential  cause  of  can- 
cer, and  withholding  judgment  as  to  the  merits  of  the 
rival  claims  of  the  intrinsic  cell  and  extrinsic  parasite, 
the  writer  wishes  briefly  to  discuss  some  of  the  existing 
factors  which  clinical  experience  clearly  prove  to  bear 
an  important  relation  to  the  actual  development  of  the 
disease. 

Heredity. — The  mysterious  influence  of  heredity,  a 
force  transmitted  by  a  single  cell  to  the  entire  organism, 
by  which  physical  attributes,  intellectual  powers,  moral 
qualities,  and  pathologic  tendencies  are  perpetrated  from 
parents  to  offspring,  markedly  influence  the  occurrence 
of  cancer.  Twist  the  facts  as  you  please,  the  inevitable 
conclusion  cannot  be  avoided  that  cancer  runs  in  fami- 
lies. Here,  as  in  the  following  sections,  the  explanation 
may  be  made  compatible  with  either  of  the  two  theories  of 
the  essential  cause  of  the  disease.  If  the  cellular  theory 
be  correct,  then  there  is  diminished  physiologic  resist- 
ance to  the  growth  of  the  matrix  of  embryonal  cells, 
and  they  assume  active  tissue  proliferation.  If,  on  the 
contrary,  the  parasitic  theory  be  true,  then  it  is  an  in- 
creased susceptibility  of  tissue  from  diminished  physio- 
logic resistance  to  action  of  the  micro-organism,  and  they 
effect  localization  and  produce  their  characteristic  results. 

Age. — So  constant  a  factor  is  age  in  the  development 

254 


FUTURE   OF   CANCER 


of  cancer  that  it  is  used  as  a  practical  diagnostic  sign  in 
doubtful  cases.  Cancer  is  a  disease  of  middle  and  ad- 
vanced life.  While  the  forces  of  growth  and  reproductive 
activity  are  greatest  the  tendency  to  cancer  is  least.  When 
cancer  develops  in  opposition  to  these  forces  the  prog- 
nosis is  gravest.  A  well-known  surgeon  once  said  with 
reference  to  the  relation  of  age  to  the  probability  of  cure, 
"The  older  the  better." 

Sex. — The  influence  of  sex  on  the  occurrence  of  can- 
cer is  demonstrated  by  the  fact  that  the  disease  occurs 
nearly  twice  as  often  in  women  as  in  men.  This  is  prob- 
ably due  to  the  functional  activity  of  the  breast  and  uterus 
in  the  one  sex  and  the  functional  inactivity  of  the  analo- 
gous organs  in  the  other. 

Race. — The  bearing  of  the  race  on  cancer  is  evident, 
as  it  is  stated  that  in  the  United  States  cancer  rarely  af- 
fects the  Indian,  and  the  negro  is  attacked  less  frequently 
than  are  the  whites.  As  a  rule,  the  higher  the  civilization 
the  more  prevalent  the  disease. 

Diet. — It  is  supposed  by  some  authorities  that  diet 
plays  an  important  role  in  the  development  of  cancer, 
but  its  influence  is  denied  by  others.  It  is  claimed  that 
the  disease  is  less  frequent  in  the  vegetarian  than  in  the 
flesh-eaters — the  statement  being  supported  by  statistics 
apparently  proving  that  nations  living  on  rice  are  less 
susceptible  than  those  living  on  animal  food,  and  that 
in  any  country  the  portion  of  the  population  which, 
either  through  taste  or  necessity,  lives  on  vegetables,  is 
more  immune  than  their  fellows  whose  diet  contains  a 
large  proportion  of  meat. 

General  Health. — The  constitutional  condition  has  an 
uncertain  influence  on  the  development  of  cancer;  but  it 

255 


THE    PAST,   PRESENT   AND 


is  stated  that  cancer  is  a  disease  of  persons  whose  pre- 
vious hfe  has  been  healthy,  and  whose  nutritive  vigor 
gives  them  otherwise  a  prospect  of  long  life. 

Traumatism. — Traumatism  is  an  important  factor  in 
cancer,  for  in  at  least  20  per  cent,  of  all  cases  of  the 
disease  the  patient  will  give  a  history  of  local  injury  to 
the  part  affected.  The  injuries  are  usually  of  trivial 
nature,  and  the  explanation  offered  is  that  serious  in- 
juries cause  vigorous  reaction,  with  complete  restoration 
of  the  part,  while  minor  injuries  are  often  followed  by 
incomplete  reaction,  and  the  tissues  are  left  with  di- 
minished pathologic  resistance. 

Local  Irritation. — It  is  a  well-accepted  fact  that  local 
irritation  acts  as  an  exciting  cause  of  cancer,  as  mani- 
fested by  the  frequency  with  which  the  disease  attacks 
parts  and  organs  most  often  the  seat  of  repeated  and  pro- 
longed irritation.  As  examples  may  be  cited  the  lip  can- 
cer of  smokers,  the  scrotal  cancer  of  chimney-sweepers 
and  the  close  association  between  gall-bladder  and  cancer 
of  the  liver. 

Geographical. — The  habitat  of  the  individual  increases 
or  diminishes  the  probability  of  cancer.  The  disease  is  rare 
in  the  arctic  and  tropical  regions,  and  frequent  in  the 
temperate  zone.  It  is  almost  unknown  in  Iceland,  Green- 
land, and  Africa,  and  common  in  America,  Europe,  Asia, 
and  Australia. 

Topographical. — The  influence  of  topographic  location 
is  demonstrated  by  the  difference  in  mortality  lecords  in 
lural  communities  and  in  manufacturing  centres.  As  a 
general  proposition,  it  may  be  stated  that  the  rate  of 


2s6 


FUTURE   OF    CANCER 


cancer  is  highest  where  the  struggle  for  existence  is  hard- 
est and  the  density  of  population  greatest. 

Dismissing  the  subject  of  the  etilogy  of  cancer,  and 
omitting  for  lack  of  space  all  reference  to  the  histology, 
symptomalogy  and  diagnosis  of  the  disease,  the  question 
of  its  treatment  will  next  be  considered. 

Treatment  of  Cancer. 

The  great  and  vital  importance  of  the  proper  manage- 
ment of  carcinoma  can  only  properly  be  appreciated  after 
a  recognition,  first  of  the  frequency  of  the  disease; 
second,  the  apparent  rapid  increase  of  the  disease,  and 
third,  the  improvement  in  results  that  has  followed  the 
modern  methods  of  radical  surgical  extirpation  of  the 
disease. 

The  following  figures  are  gathered  from  a  recent  ar- 
ticle of  Dr.  Frederick  S.  Dennis,  of  New  York.  In 
1890  the  death  rate  from  cancer  for  the  United  States 
was  53  per  100,000  population;  for  England,  67;  for 
Scotland,  60 ;  for  Austria,  52 ;  for  Ireland,  45 ;  for  Prus- 
sia, 43 ;  for  Italy,  42.  In  England  there  are  7,000  deaths  an- 
nually from  cancer  and  30,000  patients  suffer  at  all  times 
from  the  disease.  In  the  United  States,  by  the  census, 
there  were  18,000  deaths  from  cancer  in  1890  and  conser- 
vative estimates  now  place  the  death-rate  at  over  25,000 
per  annum.  Based  on  the  proportion  of  deaths  to  cases, 
as  calculated  for  England,  there  are  to-day  over  100,000 
cases  of  cancer  in  the  United  States.  Statistics  also  show 
an  apparent  alarming  and  rapid  increase  in  the  number 
of  cases  of  cancer.  It  has  been  calculated  that  in  recent 
years  cancer  of  the  breast  alone  has  increased  12  per 

257 


THE    PAST,   PRESENT   AND 


cent,  in  Connecticut ;  50  per  cent,  in  the  District  of  Colum- 
bia; 115  per  cent,  in  Rhode  Island,  and  179  per  cent,  in 
Philadelphia.  Roswell  Park  makes  the  startling  state- 
ment that  if  cancer  continues  to  increase  during  the  next 
ten  years  as  it  has  done  in  the  past  ten,  at  the  end  of  a 
decade  more  people  will  die  in  the  State  of  New  York 
from  cancer  than  will  die  from  small-pox,  typhoid  fever, 
and  tuberculosis  combined. 

It  is  but  fair  to  state  that  Senn  and  others  claim  that 
this  increase  is  more  apparent  than  real,  and  is  due  to 
more  accurate  diagnosis,  more  frequent  post-mortems, 
more  general  resort  to  operative  intervention,  and  to  in- 
creased longevity. 

Statistics  in  regard  to  the  improvement  in  the  perma- 
nent results  of  operation  for  cancer  are  prolific,  but  not 
easily  concentrated  to  comparative  figures.  Dennis  re- 
ports eighty-seven  cases  of  malignant  growths  operated 
upon  and  cured;  the  nature  of  the  disease  in  each  in- 
stance being  demonstrated  by  microscopic  examination, 
and  the  permanency  of  the  result  tested  by  careful  sub- 
sequent observations  for  a  period,  in  no  instance  less  than 
three,  and  in  some  of  over  twenty-years. 

While  Dennis'  results  are  no  better  than  those  attained 
by  many  other  surgeons,  yet  he  deserves  the  thanks  of 
the  profession  for  the  arduous  labor  he  has  performed  in 
tracing  his  cases  and  proving  the  fallacy  of  the  views  of 
many  of  the  laity  that  cancer  is  incurable. 

In  actual  practice  almost  every  conceivable  treatment 
has  been  applied  to  cancer,  and  while  the  dearly-earned 
experience  has  united  the  profession  in  the  conclusion 
that  at  the  present  time  there  is  but  one  possibility  of 

258 


FUTURE   OF    CANCER 


cure — namely,  early  and  radical  surgical  intervention — it 
will  be  well  to  review  other  methods  which  have  been 
tried  and  failed. 

Electricity. — Electricity,  which  has  promised  so  much 
in  so  many  different  fields  of  medicine,  and  which  has 
practically  yielded  so  little  of  postive  therapeutic  value, 
has  been  long,  faithfully,  and  variously  employed  in  the 
treatment  of  cancer.  Constant  and  interrupted  currents 
have  been  applied,  electrylosis  and  cataphoresis  used,  and 
lastly,  the  influence  of  the  X-ray  tested,  all  with  practi- 
cally negative  results. 

Drugs. — The  local  application  of  methylene  blue,  for- 
maldehyde, and  similar  antiseptics,  has  resulted  in  no 
good  except  to  diminish  the  offensiveness  of  discharge  in 
ulcerative  cases.  The  parenchymatous  injection  of  alco- 
hol, acetic  acid,  and  other  sclerotics  has  accomplished 
nothing  save  in  a  few  cases  where  they  have  temporarily 
arrested  the  local  extension  by  impairing  the  blood  sup- 
ply through  cicatrization  of  adjacent  tissue.  The  internal 
administration  of  iodide  of  potassium,  arsenic,  cunduran- 
go,  turpentine,  cinnamon,  clover  tea,  and  a  host  of  others 
has  served  no  purpose,  unless  it  has  been  to  keep  alive 
the  flickering  hope  of  poor  unfortunates  painfully  con- 
scious of  their  doom. 

Toxins  and  Serums. — The  injection  of  the  combined 
toxins  of  the  streptococcus  erysipelatus  and  of  the  bacillus 
prodigiosus,  which  for  a  time  excited  so  much  attention, 
has  ceased  to  be  seriously  considered.  Even  its  origina- 
tor, Coley,  states  that  it  has  only  an  inhibitory  influence 
on  carcinoma,  and  is  but  rarely  curative.  Cancroin,  a 
toxic  product  derived  from  cancerous  tissue  by  Adam- 

259 


THE    PAST,   PRESENT   AND 


kiewiez,  has  been  extensively  tried,  but  has  proved  to  be 
without  specific  virtue.  Blood  serum,  obtained  from  hor- 
ses, goats,  and  sheep,  injected  with  cancer  juice,  or  the 
toxins  of  the  supposed  cancer  protozoon,  have  likewise 
failed.  Despite  these  facts,  the  serum  therapy  of  can- 
cer offers  a  promising  and  fascinating  field  for  investi- 
gation. If  cancer  be  due  to  a  parasite,  if  it  can  be  iso- 
lated and  cultivated,  if  its  pecuHarities  can  be  studied  and 
its  idiosyncrasies  noted,  in  the  words  of  Dr.  Park,  "It  is 
not  too  much  to  hope  that  some  agent,  be  it  either  vege- 
table or  mineral  drug,  or  animal  antitoxin,  may  yet  be 
discovered  by  which  the  ravages  of  the  disease  may  be 
checked  or  prevented." 

Caustics. — Chemical  escharotics  were  once  largely  used 
by  the  profession  in  the  treatment  of  superficial  forms  of 
cancer,  but  they  have  now  been  practically  abandoned, 
and  are  only  of  interest  owing  to  their  frequent  revival 
by  quacks  and  charlatans,  who  reintroduce  them  as  new 
discoveries,  cloaked  in  mystery  and  vested  with  mar- 
vellous properties.  A  caustic  causes  coagulation  of  the 
protoplasm  of  the  cells  with  which  it  comes  in  contact. 
It  acts  chemically,  has  no  selectivity,  and  destroys  heal- 
thy and  diseased  tissue  alike.  It  produces  the  formation 
of  a  sphacelus  which  separates  from  adjacent  structures 
by  ulceration.  Its  action  is  slow  and  the  pain  produced 
prolonged  and  extreme.  Its  destruction  of  tissue  is  un- 
certain in  extent,  and  the  carcinoma  is  frequently  not  re- 
moved, and  sometimes  healthy  tissue  is  unnecessarily 
sacrificed.  It  leaves  an  open,  suppurating  wound,  which 
entails  a  long  period  of  convalescence,  and  exposes  the 

260 


FUTURE   OF    CANCER 


patient   to   the   dangers   of   secondary  hemorrhage   and 
pyemic  infection. 

When  it  is  remembered  that  the  only  object  in  the 
use  of  a  caustic  is  to  remove  the  diseased  tissue,  and  when 
it  is  known  that  this  can  be  done  much  more  speedily, 
accurately,  and  painlessly  by  the  knife,  with  shorter 
period  of  convalescence,  less  resulting  deformity,  and  di- 
minished risk  to  life,  it  is  at  first  a  matter  of  surprise 
that  cancer  quacks  prosper.  Competition  with  them, 
however,  will  soon  supply  the  explanation — competition, 
not  in  a  pecuniary  sense,  for  they  have  consistency  in 
their  effrontery,  and  their  charges  are  in  proportion  to 
their  promises — ^but  competition  in  a  higher  sense;  con- 
tention for  a  case,  not  a  fee ;  effort  to  save  a  patient  from 
what  is  believed  to  be  a  sacrifice  of  the  one  and  only 
chance  of  recovery — namely,  radical  surgical  removal  be- 
fore regional  and  general  infection  make  the  case  inoper- 
able. Quacks  have  apparently  no  professional  restric- 
tions, no  moral  obligations,  and  no  legal  responsibihties. 
Free  from  the  provisions  of  the  Code  of  Ethics  of  the 
regular  profession,  they  advertise  extensively  in  all  the 
popular  publications  of  the  day,  offering  hope  and  promis- 
ing cure  to  despairing  individuals  ready  to  grasp  at 
straws.  Communication  once  established,  the  victim  is 
bombarded  with  reprints  of  histories  of  cases  successfully 
treated,  copies  of  eulogistic  editorials  from  venal  religi- 
ous papers,  and  sweeping  letters  of  endorsation  from  ig- 
norant and  credulous  ministers  of  the  Gospel.  The  pa- 
tient secured,  the  lotion  or  paste  is  applied.  If  the  di- 
sease be  a  warty  excrescence,  or  a  benign  tumor,  or  a 
syphilitic  sore,  the  case  is  cured  and  the  result  recorded. 

261 


THE    PAST,   PRESENT   AND 


If  it  be  cancer,  the  case  dies,  and  the  profit  is  pocketed. 
Yet,  the  public,  which  has  organized  a  Society  for  the 
Prevention  of  Cruelty  to  Animals,  and  the  Legislature, 
which  has  passed  laws  to  prevent  money  being  obtained 
under  false  pretences,  stand  idly  by,  and  the  medical  pro- 
fession, when  it  attempts  to  expose  outrages  being  com- 
mitted, is  charged  with  being  actuated  by  unworthy 
motives. 

Operative  Treatment. — The  early  and  radical  use  of 
the  knife  offers  the  only  possible  cure  for  cancer.  The 
theory  that  cancer  is  a  local  manifestation  of  a  consti- 
tutional dyscrasia  has  been  abandoned.  The  fact  that 
cancer  is  at  first  a  strictly  local  disease  and  becomes 
regional  and  general  later  by  extension  and  metastasis, 
has  been  accepted.  If  the  diagnosis  of  cancer  can  be 
made  early  while  the  disease  is  yet  local,  and  if  its  anato- 
mical position  is  such  as  to  permit  of  its  complete  re- 
moval, the  prognosis  is  good.  If  the  diagnosis  of  cancer 
is  delayed  until  the  disease  has  become  regional  by  ex- 
tension through  the  lymphatics,  the  prognosis  is  bad.  If 
the  diagnosis  of  cancer  is  postponed  until  the  disease  has 
become  general  by  dissemination  through  the  veins  the 
prognosis  is  hopeless.  It  will  thus  be  seen  that  the  cases 
early  diagnosticated  are  the  ones  that  give  the  cures, 
and  the  cases  only  recognized  late  in  their  pathologic  life 
give  the  failures.  Authorities  state  that  after  the  disease 
has  been  in  existence  for  more  than  six  months  removal, 
no  matter  how  complete,  is  almost  certain  to  be  followed 
by  recurrence. 

Second  only  in  importance  to  early  diagnosis  is  the 
completeness  of  the  operation  for  the  removal  of  the  in- 

262 


FUTURE  OF  CANCER 


fected  tissue.  Heidenheim,  by  exhaustive  research,  has 
shown  the  direction  of  the  regional  extension  of  cancer, 
and  taught  the  surgeon  the  necessity  of  not  only  remov- 
ing the  organ  in  which  the  disease  originated,  but 
the  adjacent  lymphatics  as  well.  In  cancer  of  the 
breast  not  only  should  the  mammary  gland  be  amputated, 
but  the  axillary  and  possibly  the  supra-clavicular  space 
opened  and  cleared  of  all  fat  fascia  and  lymphatics.  In 
cancer  of  the  cervix,  not  only  should  the  uterus,  but  the 
retro-peritoneal  glands  of  the  pelvis,  be  removed.  In 
cancer  of  the  penis,  not  only  should  the  organ  be  sacri- 
ficed, but  the  inguinal  glands  of  both  groins  should  be 
removed.  As  operations  for  cancer  have  become  more 
radical,  the  ultimate  results  have  become  more  favorable. 


263 


Methods     to     Hasten     Epidermization, 

With   Special   Reference  to 

Skin  Grafting  * 

Every  practitioner  is  frequently  called  on  to  treat  loss 
of  cutaneous  surface  due  either  to  injury  or  disease.  If 
the  area  is  small,  repair  is  usually  rapid  and  complete,  but 
if  it  is  large,  repair  often  progresses  to  a  certain  point, 
and  then  ceases.  In  the  one  case  the  capacity  of  the  ger- 
minal cells  is  sufficient  to  meet  the  demands  made  upon 
them;  in  the  other  the  amount  of  material  required  is 
more  than  they  can  produce. 

It  is  the  object  of  this  paper  to  discuss  methods  to 
hasten  healing  in  cases  where  the  process  is  slow  or  at 
a  stand  still.  No  effort  will  be  made  to  review  the  litera- 
ture of  the  subject,  and  only  the  results  of  practical  ex- 
perience will  be  given. 

To  secure  epidermization  the  first  step  should  be  to 
stop  suppuration.  The  second  should  be  to  stimulate  nor- 
mal regeneration  and  to  protect  the  embryonal  cells  re- 
sulting. The  third,  in  case  the  first  two  are  insufficient, 
should  be  to  augment  nature's  reparative  forces  by  graft- 
ing the  bare  area  with  epithelial  tissue  of  sufficient  vitality 
not  only  to  live,  but  to  grow. 

These  three  indications  for  treatment  must  be  followed 
in  the  management  of  every  granulating  wound,  whether 
it  be  a  small  ulcer  or  an  extensive  burn.     They  cannot 


*  Read    at    a    meeting    of    the    Medical    Society    of    Virginia, 
Roanoke,  Va.,  September,   1904. 

265 


METHODS  TO  HASTEN  EPIDERMIZATION 

be  carried  out  independently,  but  must  be  combined.  They 
will  not  be  discussed  separately,  but  collectively  under 
the  different  dressings  commonly  employed. 

Moist  Dressings. — After  the  preliminary  cleaning  of 
the  wound  and  adjacent  surfaces,  the  tirst  treatment 
usually  tried  is  the  moist  dressing,  the  character  varying 
from  the  cold  water  dressing  of  our  forefathers  to  the 
moist  corrosive  dressing  of  the  antiseptic  extremist  of 
the  present  day.  The  method  of  application  consists  in 
saturating  a  pad  of  absorbent  cotton  with  the  fluid  se- 
lected, applying  it  to  the  raw  surface,  and  preventing 
rapid  evaporation  by  covering  it  with  a  layer  of  oil  silk. 
The  cotton  should  be  wet  as  often  as  it  becomes  dry,  and 
should  be  changed  as  often  as  it  becomes  soiled.  The 
solution  employed  should  not  be  a  strong  antiseptic,  as 
it  would  kill  cells  as  well  as  germs,  but  it  should  have 
an  inhibitory  action  on  microbic  life.  The  three  that  will 
be  found  most  satisfactory  are  chloral  hydrate  solution 
(chloral  hydrate  gr  Ixiv;  water  oij)  ;  Thiersch's  solution 
(salicylic  acid  gr  xxx,  boric  acid  drams  iij,  water  oij)  ; 
and  acetate  of  aluminum  solution  (alum  drams  vj,  acetate 
lead  drams  ixss,  water  oij ) .  They  may  be  used  either  hot 
or  cold,  and  should  be  employed  in  conjunction  with  rest 
and  elevation.  I  have  had  many  a  swollen  and  rebellious 
leg  ulcer  come  to  me,  scarred  with  caustics,  gritty  with 
antiseptic  powders,  or  filthy  with  greasy  ointments,  but 
not  one  that  did  not  yield  readily  when  the  patient  was 
put  to  bed,  the  limb  elevated,  and  the  part  treated  with  hot 
chloral  dressings. 

Dry  Dressings. — The  treatment  of  granulating  surfaces 
by  dusting  them  with  antiseptic  powders  has  been  made 
undeservedly  popular  by  the  advertisements  of  firms  that 

266 


ESPECIALLY  SKIN  GRAFTING 

had  proprietary  preparations  to  sell.  The  powders  most 
frequently  employed  are  iodoform,  aristol,  dermatol,  bis- 
muth, boric  acid  and  oxide  of  zinc.  In  some  cases  they 
do  good,  but  in  most  instances  they  do  harm.  Chemically 
they  destroy  germs  and  lessen  suppuration ;  mechanically 
they  destroy  embryonal  cells  and  retard  healing.  When 
first  applied  to  a  wound  decided  improvement  is  seen, 
but  continued  use  is  followed  by  irritation  due  to  absorp- 
tion of  serum  and  the  formation  of  crystalline  concre- 
tions that  act  as  foreign  bodies,  or  broad  incrustations 
that  prevent  the  escape  of  pus  or  other  wound  secretions. 
I  am  free  to  say  that  I  do  not  use  dusting  powders.  There 
has  not  been  a  grain  of  iodoform  in  my  private  hospital 
for  the  last  three  years,  and  its  banishment  has  not  proved 
detrimental  to  patients,  but  exceeding  beneficial  to  the 
atmosphere  of  the  institution. 

Oleaginous  Dressings. — The  use  of  salves  and  oint- 
ments in  the  treatment  of  superficial  wounds  has  fallen 
into  unmerited  disfavor.  Because,  before  the  day  of  anti- 
septic surgery,  they  were  abused  is  no  reason  why  they 
should  now  no  longer  be  used.  Some  preparations  quickly 
become  rancid  and  should  be  avoided  ;  others  remain  sterile 
indefinitely,  and  may  safely  be  employed.  Vaseline,  lano- 
line  and  castor  oil,  plain  or  medicated,  will  give  better 
results  in  some  cases  than  any  other  application.  They 
exert  a  feeble  antiseptic  action,  thus  lessening  suppura- 
tion ;  they  exclude  the  air,  thus  relieving  pain ;  and  they 
prevent  the  adhesion  of  overlying  dressings,  thus  saving 
the  embryonal  cells  from  mechanical  injury.  In  exten- 
sive burns  I  have  found  nothing  better  in  the  early  stages 
than  a  5  per  cent,  mixture  of  ichthyol  and  vaseline,  and  in 
sluggish  granulations,  especially  of  a  tuberculous  char- 

267 


METHODS  TO  HASTEN  EPIDERMIZATION 

acter,  I  have  never  failed  to  see  good  come  from  the 
appHcation  of  a  combination  of  i  per  cent.  carboHc  acid, 
5  per  cent.  Balsam  Peru,  and  94  per  cent,  castor  oil. 

Nutritive  Dressings. — Considerable  benefit  will  some- 
times be  derived  in  the  treatment  of  a  granulating  wound 
by  the  use  of  a  dressing  that  supplies  food  directly  to 
the  germinal  cells  and  their  offspring.  Proliferation  is 
often  arrested  by  starvation,  and  feeding  is  the  logical 
remedy.  The  agent  employed  should  be  aseptic,  non- 
irritating,  and  should  contain  nutritive  material  in  an 
easily  absorbable  form.  The  preparation  that  in  my 
opinion  most  nearly  meets  these  requirements  is  Valen- 
tine's Meat  Juice.  It  is  sterile,  contains  no  alcohol,  is  rich 
in  food  stuff,  and  has  practically  the  same  percentage 
of  sodium  chloride  as  the  normal  serum  of  the  blood.  It 
should  be  diluted  with  three  parts  of  water,  warmed  to 
the  temperature  of  the  body,  and  applied  on  cotton  in 
the  form  of  a  moist  dressing.  My  experience  has  been 
that  it  does  a  great  deal  of  good  for  a  short  while,  but 
then  loses  its  effect.  As  soon  as  pale  granulations  be- 
come pink  and  healthy  is  has  fulfilled  its  function,  and 
should  give  place  to  some  other  dressing. 

Alterative  Dressings. — Cells,  like  individuals,  some- 
times without  assignable  reason,  develop  disturbances  of 
nutrition  requiring  alterative  treatment.  In  the  manage- 
ment of  a  granulating  wound  there  is  often  call  for  local 
medication.  Experience  alone  can  teach  the  surgeon  the 
agent  to  employ  and  the  time  and  method  of  its  appli- 
cation. Nitrate  of  silver,  mercurial  ointment,  chloride 
of  zinc  and  sulphate  of  copper  are  all  useful  and  time- 
honored  remedies.  Among  newer  preparations  must  be 
mentioned  proto-nuclein.     I  have  several  times  seen  in- 

268 


ESPECIALLY  SKIN  GRAFTING 

dolent  or  foul  granulating  areas  that  had  detied  a  half 
dozen  other  lines  of  treatment  improve  under  its  use 
as  if  by  magic. 

Protective  Dressings. — In  direct  contrast  to  granulat- 
ing surfaces  that  need  stimulating  or  alterative  treat- 
ment are  those  that  are  doing  well  and  only  require  pro- 
tection. When  the  wound  is  healthy  and  healing  pro- 
gressing satisfactorily,  nothing  is  more  mischievous  than 
meddlesome  interference.  All  that  should  be  done  is  to 
prevent  infection  by  cleanliness,  and  to  avoid  injury  to 
the  newly  formed  cells  by  mechanical  protection.  Clean- 
liness is  secured  by  changing  the  dressings  as  frequently 
as  they  become  soiled  and  bathing  the  wound  with  nor- 
mal salt  solution.  Protection  is  best  accomplished  by  in- 
terposing some  impervious  material  between  the  granula- 
tions and  the  meshes  of  the  overlying  gauze,  into  which 
they  would  otherwise  become  entangled.  In  my  exper- 
ience, the  best  results  follow  the  use  of  strips  of  rubber 
dam,  collodion  tilm,  or  cargile  membrane  placed  lattice- 
wise  so  as  to  afford  drainage.  Rubber  dam  is  the  material 
used  by  dentists,  and  can  be  sterilized  by  boiling.  Col- 
lodion film  can  be  prepared  by  pouring  collodion  on  an 
aseptic  sheet  of  glass,  allowing  it  to  harden  and  then 
cutting  it  in  strips.  Cargile  membrane  is  made  from  the 
peritoneum  of  an  ox,  and  can  be  bought  on  the  market 
in  germ  proof  envelopes. 

Proliferating  Dressings. — When  the  destruction  of 
skin  is  so  extensive  that  the  normal  reparative  power 
is  insufficient  to  cover  the  granulating  area  with  epithelial 
cells,  recourse  must  be  made  to  skin  grafting.  It  has 
long  been  known  that  bits  of  cuticle  properly  planted 
on  fresh  wounds  or  healthy  granulating  surfaces  would 

260 


METHODS  TO  HASTEN  EPIDERMIZATION 

become  adherent  and  grow,  thus  protecting  underlying 
structures  and  acting  as  independent  foci  of  epidermiza- 
tion  for  adjacent  tissue.  The  application  of  this  fact  with 
epithelial  cells  secured  from  different  sources  and  ap- 
plied by  various  methods  has  enabled  the  surgeon  to  heal 
wounds  quickly  and  certainly  which  otherwise  would  be 
slow  to  close,  or  perhaps  become  permanent  ulcers. 

Skin  grafting,  when  practiced  on  newly  made  wounds, 
is  called  primary  grafting.  When  practiced  on  granulat- 
ing surfaces  it  is  called  secondary  grafting.  If  the  sur- 
face be  a  fresh  one,  care  must  be  taken  perfectly  to  arrest 
hemorrhage  before  applying  the  grafts,  otherwise  bleed- 
ing will  detach  them.  If  the  surface  be  an  old  one,  care 
must  be  taken  to  stop  suppuration  before  applying  the 
grafts ;  otherwise  pus  germs  will  devitalize  them. 

Skin  grafts  may  be  obtained  from  the  patient,  and 
then  they  are  called  autografts;  they  may  be  cut  from 
another  person,  and  then  they  are  called  heterograf ts ;  or 
they  may  be  secured  from  an  animal  of  a  different  species, 
and  then  are  called  zoografts. 

There  are  three  recognized  methods  of  skin  grafting. 
Reverdins',  consisting  in  cutting  small  particles  from 
the  superficial  layers  of  the  skin  with  scissors  and  plant- 
ing them  at  intervals  over  the  surface  to  be  covered ; 
Thiersch's,  consisting  in  cutting  broad  strips  from  the 
superficial  layers  of  the  skin  with  a  razor  and  placing 
them  so  as  completely  to  cover  the  wound  area ;  and 
Wolfe's,  consisting  in  the  dissection  of  a  piece  of  skin 
the  entire  thickness  of  the  structure  and  fitting  it  to  the 
defect  to  be  remedied. 

The  dressing  after  any  of  the  above  methods  consists 
of  a  lattice  work  of  protective  strips  over  which  is  placed 

270 


ESPECIALLY  SKIN  GRAFTING 

a  pad  of  gauze  wet  with  normal  salt  solution.  This 
should  be  removed  and  replaced  at  the  end  of  the  third 
day,  and  the  subsequent  management  of  the  case  carried 
out  on  general  surgical  principles. 

The  instruments  required  for  skin  grafting  are  so  few, 
the  operation  itself  so  simple,  and  the  results  secured  so 
immediate  and  satisfactory,  that  the  surgeon  who  does 
not  avail  himself  of  it  in  suitable  cases  does  an  injustice 
both  to  himself  and  his  patient. 

Primary  skin  grafting  should  be  employed  after  the 
removal  of  an  epithelioma  or  other  superficial  growth, 
provided,  infection  can  be  prevented,  hemorrhage  ar- 
rested, and  ligatures  and  sutures  avoided.  The  depres- 
sion due  to  the  removal  of  tissue  will  fill  up  beneath  the 
grafts  and  the  deformity  will  be  less  than  anticipated. 
I  have  removed  a  growth  the  size  of  a  silver  dollar  from 
a  nose,  grafted  it  at  once  with  skin  from  the  arm, 
and  discharged  the  patient  with  a  perfectly  healed  wound 
in  ten  days  from  the  operation. 

Secondary  skin  grafting  should  be  employed  when  liga- 
tures are  used  to  arrest  bleeding,  or  sutures  to  secure 
partial  coaptation ;  where  infection  is  likely  or  already 
exists,  or  where  the  excavation  is  deep  and  a  large  amount 
of  granulation  tissue  is  necessary  to  fill  it.  In  operating 
for  cancer  of  the  breast,  where  the  approximation  of  the 
margins  of  the  wound  is  secondary  to  extirpation  of  the 
diseased  tissue,  I  remove  the  malignant  growth  as  com- 
pletely as  possible,  bring  the  cut  edges  of  the  skin  to- 
gether as  nearly  as  practicable,  apply  a  protective  dress- 
ing, and  a  week  or  ten  days  later  remove  the  stitches  and 
skin  graft  the  granulating  area. 

Reverdins'  method  should  be  employed  where  the  area 

271 


METHODS  TO  HASTEN  EPIDERMIZATION 


to  be  covered  is  small,  and  where  the  administration  of 
a  general  anesthetic  is  contraindicated.  The  surface  to 
be  grafted  and  the  site  from  which  the  grafts  are  to  be 
taken  should  both  be  prepared.  The  skin  is  then  elevated 
into  a  cone  by  means  of  a  sharp  tenaculum  and  a  small 
piece  snipped  from  its  superficial  layer  by  means  of  a  pair 
of  curved  scissors.  The  fragment  is  at  once  transferred 
to  the  area  to  be  grafted  and  carefully  seated  on  the  gran- 
ulations, care  being  taken  to  prevent  the  edges  curling 
inward,  thus  preventing  apposition  of  raw  surfaces.  This 
is  repeated  until  a  sufficient  number  of  grafts  have  been 
planted  quickly  to  stud  the  bare  area.  The  operation  of 
cutting  the  grafts  can  be  made  painless  by  the  use  of  the 
chloride  of  ethyl  spray.  I  have  found  the  above  method 
very  satisfactory,  especially  in  weak,  nervous  patients, 
where  a  more  formidable  operation  would  have  a  bad 
effect.  The  space  between  the  grafts  is  rapidly  covered 
and  the  resulting  scar  is  good. 

Thiersch's  method  should  be  used  when  the  surface  to 
be  covered  is  large,  and  when  the  patient  is  either  under 
an  anesthetic  or  its  administration  will  be  compensated 
for  by  the  more  rapid  recovery  it  promises.  The  grafts 
are  obtained  by  making  the  skin  tense  and  fat,  either  man- 
ually or  by  special  hooks,  and  cuttings  off  the  superficial 
layers  by  a  to  and  fro  sawing  motion  of  a  sharp  razor. 
The  larger  the  size  of  the  grafts  the  better.  Usually  they 
are  an  inch  wide  and  four  or  five  inches  in  length.  Care 
should  be  taken  to  remove  only  the  upper  layer  of  the 
skin,  otherwise  the  wound  inflicted  may  prove  as  difficult 
to  cure  as  the  wound  the  surgeon  is  endeavoring  to 
remedy.  As  the  grafts  are  cut  they  are  dropped  into 
a  basin  of  warm  saline  solution.     Afterwards  they  are 

272 


ESPECIALLY  SKIN  GRAFTING 

carefully  placed  on  the  area  to  be  grafted,  the  edge  of 
one  graft  overlapping  that  of  the  adjacent  one.  Thiersch's 
method  of  skin  grafting  is  the  one  most  frequently  prac- 
ticed, and  the  one  that  gives  the  most  brilliant  results. 
The  objections  to  it  are  that  it  necessitates  the  use  of  an 
anesthetic  and  the  site  from  which  the  grafts  are  cut 
is  painful  and  takes  some  days  to  heal. 

Wolfe's  method  should  only  be  employed  in  exceptional 
cases.  The  surface  of  the  area  to  be  grafted  should  be 
thoroughly  revivified  and  the  margins  made  fresh  and 
vertical.  All  bleeding  should  be  completely  arrested.  The 
new  skin  to  be  used  as  a  graft  must  be  dissected  from 
some  other  site.  The  entire  thickness  of  the  skin  should 
be  removed,  but  no  subcutaneous  fat  taken  with  it.  The 
outline  of  the  incision  should  preferably  be  an  ellipse 
to  permit  of  closure  of  the  defect  by  sutures.  The  skin 
removed  should  be  one-third  larger  than  the  defect  to 
be  covered  to  allow  for  shrinkage.  The  graft  after  hav- 
ing been  placed  in  its  new  position  may  be  retained  by 
sutures  or  reliance  placed  on  overlying  dressings.  The 
method  is  uncertain  in  results,  but  may  sometimes  be 
used  with  advantage.  I  remember  one  case  where  I 
planted  a  single  piece  of  skin,  having  an  area  of  some 
1 6  square  inches.  The  graft  was  obtained  in  retrench- 
ing the  scrotum  of  a  man  for  varicocele,  and  was  planted 
on  a  woman  who  had  been  operated  on  some  days  pre- 
viously for  cancer. 

In  addition  to  the  recognized  methods  of  skin  graft- 
ing just  described,  occasional  reference  will  be  found  to 
grafting  wounds  with  the  skin  of  an  egg,  with  the  pellicle 
of  a  blister,  and  with  dry  epidermal  scales,  such  as  scrap- 
ings from  callosities  or  dandruff  from  the  head.     I  have 

273 


METHODS  TO  HASTEN  EPIDERMIZATION 

tried  all  these  expedients  with  unsatisfactory  results.  The 
only  reasonable  sources  from  which  to  obtain  vital  epithe- 
lial tissues  are  the  skin  of  the  patient,  autografts ;  the 
skin  of  another  individual,  heterograf ts ;  and  the  skin 
of  a  lower  animal,  zoografts. 

Autografts  are  usually  cut  from  the  patient's  thigh  or 
shoulder.  They  furnish  the  material  most  likely  to  prove 
successful,  and  should  be  employed  except  in  cases  where 
the  patient's  general  condition  is  bad  or  where  the  area 
to  be  grafted  is  very  extensive.  The  practice,  however, 
is  not  free  from  annoyance  or  distressing  complications. 
A  woman  came  to  me  not  long  ago  with  an  epithelioma 
of  long  standing  on  the  vertex  of  her  head.  It  originated 
in  an  old  scar  and  was  about  four  inches  in  diameter. 
I  shaved  her  head,  made  an  incision  around  the  growth, 
and  scalped  her.  The  wound  was  treated  with  a  moist 
antiseptic  dressing  until  it  had  filled  with  healthy  granula- 
tions to  the  level  of  the  margins.  I  then  skin  grafted 
the  bare  surface  by  Thiersch's  method,  cutting  the  grafts 
from  the  deltoid  region.  The  grafts  took  beautifully,  and 
in  two  weeks  she  was  apparently  well.  Several  months 
later  she  came  back  to  the  hospital.  Her  head  looked 
like  a  tonsured  monk,  and  the  skin  on  the  bald  area  was 
perfect,  but  the  shoulder  from  which  the  grafts  had  been 
cut  gave  her  much  pain.  On  examination  it  was  found 
to  be  the  seat  of  a  keloid  growth  the  size  of  a  man's 
hand.    I  had  cured  her  of  cancer  only  to  give  her  keloids. 

Heterografts  are  obtained  from  another  individual, 
from  amputated  extremities,  or  from  fresh  cadavers. 
They  usually  grow  well,  and  should  be  employed  when 
they  can  be  secured  from  a  satisfactory  source.  They 
entail  the  danger  of  infecting  the  patient  with  syphilis, 
tuberculosis,  and  other  diseases,  which  must  be  carefully 

274 


ESPECIALLY  SKIN  GRAFTING 

guarded  against.  The  question  of  the  necessity  of  the 
grafts  being  the  same  color  as  the  skin  of  the  patient 
on  which  they  are  planted  is  still  unsettled.  It  is  claimed 
that  a  negro  skin  grafted  on  a  white  person  will  lose 
its  pigment,  and  that  white  skin  grafted  on  a  negro  will 
become  pigmented.  A  few  years  ago  I  had  an  oppor- 
tunity to  test  the  question.  A  negro  man  as  black  as  the 
ace  of  spades  had  his  leg  crushed.  It  w^as  amputated, 
but  the  flaps  sloughed,  leaving  a  granulated  area  three  or 
four  inches  in  diameter.  It  was  determined  to  graft  skin 
and  my  assistants  were  directed  to  prepare  the  man 
for  the  operation  at  the  next  clinic.  When  the  patient 
was  brought  into  the  amphitheatre  I  had  just  finished 
amputating  the  leg  of  a  white  man.  On  the  spur  of 
the  moment  I  decided  to  cut  the  grafts  from  the  white 
leg  and  plant  them  on  the  black  one.  The  operation 
was  done  by  Thiersch's  method  with  satisfactory  results, 
the  patient  being  discharged  as  cured  in  three  weeks' 
time.  Two  years  afterwards  the  man  came  back  to  the 
clinic  on  account  of  some  other  trouble.  xAn  examina- 
tion of  the  grafted  stump  showed  that  the  grafts  were 
as  white  as  they  were  on  the  day  they  were  planted. 
While  one  case  proves  little,  the  result  is  significant.  It 
has  for  obvious  reasons  deterred  me  from  reversing  the 
experiment  and  grafting  a  negro's  skin  on  a  white  patient. 
Zoografts  are  obtained  from  one  of  the  lower  animals, 
the  frog,  chicken,  pig,  dog,  cat,  rabbit  or  guinea  pig 
being  most  commonly  used.  They  do  not  grow  as  readily 
as  grafts  from  the  skin  of  a  human  oeing,  and  they  should 
not  be  employed  when  other  sources  of  supply  are  avail- 
able. Still  there  are  certain  conditions  where  they  are  not 
only  useful,  but  are  the  only  means  by  which  the  patient 
can  be  cured. 

275 


METHODS  TO  HASTEN  EPIDERMIZATIOX 

A  small  negro  child  was  brought  to  the  clinic  last 
winter,  who  had  been  severely  scalded  several  months 
before.  Some  healing  had  occurred  at  the  margins  of 
the  burns,  but  effort  at  repair  had  ceased,  and  there  was 
a  granulating  surface  on  the  body  covering  an  area  of 
over  one  hundred  square  inches.  The  child  was  treated 
until  the  granulations  were  healthy,  and  then  came  the 
question  of  where  to  get  the  skin  with  which  to  graft 
it.  The  child  was  too  small  and  its  condition  too  feeble 
to  furnish  the  grafts  from  its  own  person.  The  mother, 
relations  and  friends  all  declined  to  make  the  necessary 
sacrifice,  no  jail  bird  would  volunteer  as  a  victim  even 
at  the  promise  of  liberty,  and  applications  at  all  the  hos- 
pitals in  the  city  seemed  to  show  that  for  the  time  at 
least  surgeons  had  stopped  amputating  limbs.  As  a  last 
resort,  recourse  was  made  to  zoografts.  A  healthy  six 
weeks'  pig  of  chocolate  color  was  purchased.  It  was 
carefully  shaved  and  given  frequent  scribbings  and  anti- 
septic baths.  The  day  before  the  operation  the  belly  was 
prepared  as  if  for  abdominal  section.  The  grafting  was 
done  before  the  class  of  the  University  College  of  Medi- 
cine. The  pig  was  brought  in  on  one  table,  the  pickaninny 
on  another.  Grafts  were  cut  from  the  belly  of  the  pig 
and  planted  on  the  back  of  the  child.  The  usual  dress- 
ings were  applied,  and  for  two  weeks  everything  went 
well,  and  it  was  thought  the  operation  had  been  com- 
pletely successful.  The  wound  itched,  however,  and  one 
night  the  child  got  its  hands  beneath  the  dressing  and 
scratched  off  a  large  portion  of  the  new  and  tender  skin. 
While  the  result  was  a  partial  failure,  enough  of  grafts 
remained  to  demonstrate  that  pig  skin  would  grow.  More 
recently  I  have  had  other  cases  that  were  perfectly  cured 
by  this  method. 

2/6 


To  Cut  or  Crush  In  Stone  of  the 
Urinary  Bladder?  * 

The  question  whether  to  cut  or  crush  in  cases  of  stone 
in  the  urinary  bladder  is  no  new  one,  as  Uthotomy  and 
lithotrity  have  both  been  practiced  for  over  a  tliousand 
years.  The  opinion  of  the  profession,  as  to  the  relative 
value  of  the  two  methods  has  varied,  first  one  and  then 
the  other  gaining  ascendency. 

In  the  first  century  Celsus  wrote  a  clear  description  of 
lithotomy,  and  the  operation  was  frequently  performed. 
In  the  tenth  century.  Albueasis  described  an  instrument 
which  could  be  passed  along  the  urethra,  ''seize  the  stone, 
crush  it,  if  soft,  and  remove  it."  In  the  seventeenth 
century  Beaulieu,  a  Franciscan  monk,  performed  several 
thousand  perineal  lithotomies  and  is  reported  to  have 
operated  on  thirty-eight  consecutive  cases  in  Versailles 
without  a  death. 

In  1818  Civiale  invented  his  litholabe  and  some  years 
afterwards  reported  seventy-eight  cases  in  which  he  had 
crushed  and  removed  stone,  with  five  deaths.  In  1878 
Gross  advocated  the  cutting  operation  and  reported  163 
lithotomies,  with  fourteen  deaths.  In  the  same  year 
Bigelow  invented  his  evacuator,  and  the  possibility  of 
doing  lithotrity  at  one  sitting  (or  litholapaxy,  as  it  was 
then  called)  created  great  enthusiasm.  In  1884  Henry 
Thompson  reported    116    cases    of    lithotrity,    with    six 


*  Read    at   a   meeting   of   the   Tri-State    Medical   Association, 
Richmond,  Va.,  February,  1901. 

277 


TO  CUT  OR  CRUSH  IN  STONE  OF 

deaths.  In  1890  Hunter  McGuire  reported  twenty-six 
cases  of  supra-pubic  cystotomy  for  stone,  with  one  death. 
In  1893  Chismore  reported  fifty-four  cases  of  lithotrity, 
done  by  a  series  of  short  sittings  under  cocaine,  with  no 
deaths. 

Having  attempted  to  show  the  curious  vacillation  of 
surgical  opinion  as  to  the  relative  merits  of  the  two  opera- 
tions in  the  past,  I  will  now  try  to  find  expression  for 
the  accepted  views  of  the  present.  I  believe  it  can  be 
most  fairly  done  by  quoting  from  new  and  standard  text- 
books, which  treat  of  the  subject. 

White  and  Martin. — "The  two  received  methods  of 
treatment  are  litholapaxy  and  cystotomy.  Lithclapaxy 
is  in  both  adults  and  children  the  method  of  choice." 

Lydston. — "The  supra-pubic  operation  is  so  safe  in 
favorable  cases  that  it  is  preferable  to  litholapaxy  unless 
the  surgeon  is  expert  in  its  performance." 

An  American  Text-Book  of  Surgery. — "The  possible 
methods  of  removing  a  given  stone  from  the  male  blad- 
der are  perineal  lithotomy,  supra-pubic  lithotomy  and 
litholapaxy.  The  remarkable  changes  brought  about  by 
the  introduction  of  the  last  named  method  has  greatly 
reduced  the  field  of  the  first  two." 

Wyeth. — "The  conditions  in  which  lithotrity  is  to  be 
preferred  to  lithotomy  are  rare." 

Treves. — "Litholapaxy  is  now  the  recognized  opera- 
tion for  all  cases  of  vesical  calculus  in  males." 

Moullin. — "Calculi  must  be  removed  from  the  bladder 
by  crushing  or  cutting.  The  former  is  more  common 
and  has  to  a  great  extent  superseded  the  latter." 

Wharton  and  Curtis. — "Lithotomy  is  indicated  m  cases 
not   suited   for  crushing,   although   the   recent   improve- 

278 


THE  URINARY  BLADDER 


ments  in  supra-pubic  cystotomy  bid  fair  to  make  it  the 
rival  of  the  method  by  crushing  in  all  cases." 

From  the  extracts  given  it  will  be  seen  that  both 
methods  are  advised,  but  the  surgeon  is  taught  by  the 
majority  of  the  authorities  to  perform  lithotrity  as  the 
operation  of  election  and  lithotomy  as  the  operation  of 
compulsion.  In  other  words,  that  the  cutting  operation 
should  only  be  done  when  the  crushing  operation  is  im- 
possible. I  believe  this  teaching  is  a  survival  of  the  pre- 
antiseptic  era  and  does  not  accord  with  the  practice  of 
the  modern  surgeon.  Twenty  years  ago,  when  the  use 
of  the  knife  was  attended  by  danger  to  life,  from  septi- 
cemia, or  slow  and  complicated  convalescense  from  sup- 
puration, it  was  undoubtedly  sound,  but  to-day — with  the 
aseptic  and  antiseptic  technique  and  the  perfection  of  the 
supra-pubic  operation — it  is  false  and  misleading.  From 
a  limited  personal  experience  with  both  operations,  and 
a  careful  study  of  the  literature  of  the  subject,  I  believe 
lithotomy  should  be  the  operation  most  frequently  per- 
formed and  lithotrity  reserved  for  a  few  carefully  se- 
lected cases.  The  demonstration  of  the  truth  of  this 
statement  can  best  be  made  by  a  comparison  of  the  ad- 
vantages and  disadvantages  of  the  two  operations  under 
separate  headings. 

Mortality. — Figures  seem  to  bhow  that  lithotrity  is 
safer  than  lithotomy.  But  in  making  a  deduction  from 
statistics  it  must  be  remembered  that  they  are  based 
largely  upon  work  done  before  the  introduction  of  anti- 
septics ;  that  simple  and  easy  cases  were  crushed  and 
difficult  and  complicated  cases  cut ;  and,  finally,  that  the 
results  of  a  few  expert  lithotritists  are  compared  with 
those  secured  by  a  number  of  average  lithotomists. 

279 


TO  CUT  OR  CRUSH  IN  STONE  OF 

Requisite  Skill  and  Experience. — Lithotrity  is  un- 
doubtedly a  more  delicate  and  difficult  operation  than 
lithotomy.  It  is  blind  surgery,  liable  to  be  attended  by 
annoying  complications  or  dangerous  accidents,  and 
should  not  be  undertaken  by  one  not  thoroughly  familiar 
with  the  manipulation  of  instruments  in  the  urethra  and 
bladder.  Lithotomy,  especially  if  done  by  the  supra- 
pubic route,  is  one  of  the  simplest  operations  in  surgery 
and  may  safely  be  attempted  by  any  one  of  fair  exper- 
ience in  general  operative  work. 

Injury  to  the  Soft  Parts  and  Septic  Sequences. — It  is 
claimed  that  lithotrity  creates  no  breach  of  continuity  of 
tissue,  while  lithotomy  leaves  a  wound  of  considerable 
gravity,  and  therefore,  the  former  operation  is  followed 
by  more  rapid  recovery.  This  is  true  in  selected  cases 
in  the  hands  of  expert  operators,  but  in  many  instances, 
where  the  stone  is  large  and  hard,  and  the  surgeon  less 
experienced,  manipulations  are  prolonged  and  rough,  and 
there  is  considerable  bruising  and  laceration  of  the 
mucous  lining  of  the  urethra  and  bladder.  Copious 
hemorrhage  is  not  uncommon  and  the  bleeding  points 
are  inaccessible  to  direct  hemostasis.  There  is  practi- 
cally no  drainage,  and  the  septic  sequences  sometimes 
follow,  manifested  by  urethral  fever,  urethritis,  cystitis, 
p''0statitis,  epidydimitis  or  phlebitis. 

In  lithotomy,  especially  if  done  by  the  supra-pubic 
method,  there  is  no  contusion  of  the  mucosa  of  the  uri- 
nary tract,  but  simply  a  clean  cut  incision  through  unim- 
portant structures.  There  is  practically  no  bleeding,  and 
if  it  does  occur  from  complications,  it  can  be  con- 
trolled by  the  ligation  of  vessels  or  direct  tamponade  of 
the  bladder.     If  sepsis  follows,  which  is  unlikely,  owing 

280 


THE  URINARY  BLADDER 


to  the  free  drainage  afforded,  it  can  be  combated  by  irri- 
gation of  the  wound,  bladder  and  urethra  with  antiseptic 
solutions.  The  duration  of  convalescence  after  lithotrity 
is  uncertain.  It  may  be  shorter  than  lithotomy — it  may 
be  longer. 

Ability  to  Diagnosticate  and  Treat  Other  Pathologic 
Conditions. — Stone  in  the  bladder  is  usually  found  at  the 
two  extremes  of  life.  In  the  young  it  is  usually  uncom- 
plicated ;  in  the  old  it  is  often  associated  with  enlargement 
of  the  prostate,  severe  cystitis,  or  vesical  tumors.  Litho- 
tomy has  the  advantage  in  both  instances,  as  it  avoids 
the  dilatation  of  the  undeveloped  penis  and  small  urethra 
of  the  one — with  the  danger  of  incontinence  and  impo- 
tency ;  and  affords  direct  examination  of  the  interior  of 
the  bladder  in  the  other,  making  accessible  to  surgical 
correction  any  co-existing  disease  present,  and  affording 
subsequently  the  necessary  drainage  of  the  cavity  of  the 
viscus. 

Permanency  of  Results. — There  is  certainly  more  lia- 
bility to  the  recurrence  of  stone  after  lithotrity  than 
after  lithotomy.  In  old  men,  with  enlarged  prostates,  it 
is  impossible  to  be  sure  of  removing  all  fragments  after 
crushing,  and  it  is  also  possible  to  overlook  a  small  stone 
in  cases  of  multiple  calculi.  If  a  single  particle  is  re- 
tained in  the  bladder  it  will  act  as  an  exciting  cause  to 
the  predisposing  diathesis  and  result  in  the  production 
of  a  new  stone.  I  recall  the  case  of  an  old  man  with 
a  sacculated  bladder,  in  whom  stone  was  twice  crushed. 
On  his  third  return  to  the  hospital  I  did  a  supra-pubic 
lithotomy  and  removed  five  small  calculi.  Since  then 
he  has  remained  well. 

Simplicity  and  Freedom  from  Mechanical  Complica- 

281 


TO  CUT  OR  CRUSH  IN  STONE  OF 

tions. — While  questions  of  economy  of  instruments  have 
no  place  in  surgery,  and  the  fact  that  lithotrites  and  evacu- 
ators  are  expensive  and  perishable,  is  no  argument  against 
lithotrity,  the  simplicity  and  freedom  from  dependence  on 
the  mechanical  action  of  complicated  instruments  is  a 
strong  point  in  favor  of  lithotomy.  Many  cases  are  report- 
ed where  surgeons  had  clogging,  bending  or  breaking  of 
the  blades  of  a  lithotrite  to  occur  in  the  bladder,  and 
were  forced  to  resort  to  the  knife  to  complete  the  opera- 
tion. Only  recently  I  found  myself  in  a  predicament 
which  would  have  been  ludicrous  if  it  had  not  been 
dangerous.  I  was  crushing  a  soft  stone  of  medium  size 
in  the  bladder  of  a  boy,  aged  seventeen,  who  weighed 
nearly  three  hundred  pounds ;  the  operation  of  lithotrity 
being  selected  on  account  of  the  patient's  obesity.  The 
stone  was  readily  seized  and  crumbled  at  the  first  turn 
of  the  screw.  The  instrument  was  opened  and  several 
of  the  fragments  caught  and  broken.  It  was  then  observed 
that  the  blades  would  not  close.  Every  known  expedient 
was  tried  to  free  the  impaction,  but  failed.  A  supra- 
pubic cystotomy  was  finally  done,  a  sticky,  gummy  mass 
cleared  from  the  jaws  of  the  lithotrite  and  the  instrument 
closed  and  withdrawn.  A  subsequent  interrogation  of  the 
boy  secured  the  confession  that  some  time  before  his  ad- 
mission to  the  hospital  he  had  introduced  a  bolus  of 
chewing-gum  into  his  urethra,  which  had  slipped  from 
his  grasp  and  passed  into  th^  bladder,  doubtless  forming 
the  nucleus  of  the  stone. 

Range  of  Application. — Lithotomy  may  be  done  in 
any  case  and  has  no  limitations  other  than  those  of  gen- 
eral surgery.  Lithotrity  is  admitted  by  its  advocates  to 
be  contra-indicated  in  the  following  conditions 

282 


\. 


^'^-»- 


FlG.  7 — Specimens  of  Stone  showing  Foreign  Bodies  as  Nuclei. 


THE  URINARY  BLADDER 


1st.  When  the  stone  is  hard  and  cannot  be  crushed 
by  instruments  capable  of  being  used  through  the  urethra. 

2d.  When  the  stone  is  large  and  cannot  be  grasped 
by  reasonable  separation  of  the  jaws  of  the  lithotrite. 

3d.  When  the  stone  is  brittle  and  the  resulting  frag- 
ments sharp  and  irregular. 

4th.    When  the  stone  is  fixed  or  encysted. 

5th.  When  the  stone  has  a  foreign  body  as  a  nucleus 
which  cannot  be  crushed  and  removed. 

6th.  When  the  prostate  is  enlarged,  or  the  bladder 
contracted,  making  it  difficult  to  seize  the  stone. 

7th.  When  there  is  a  tight  or  impassable  urethral 
stricture,  requiring  a  long  operation  to  relieve. 

8th.  When  there  is  ankylosis  of  the  hip  joint  in  a 
position  embarrassing  the  movements  of  the  lithotrite. 

9th.  When  the  general  condition  of  the  patient  is  such 
as  to  make  shock  dangerous  and  rapid  work  necessary. 

In  corroboration  of  the  above  I  wish  to  exhibit  some 
specimens  of  stone  with  foreign  bodies  as  nuclei,  re- 
moved by  my  father.  Dr.  Hunter  McGuire,  by  lithotomy. 
It  is  obvious  that  an  effort  to  operate  by  lithotrity  would 
have  resulted  in  failure. 

In  the  history  of  the  cases  on  which  he  operated  for 
vesical  calculi  there  are  nine  instances  of  stones  with 
foreign  bodies  as  nuclei,  as  follows:  four  hairpins,  two 
bullets,  one  piece  of  bone,  one  piece  of  gum  catheter, 
and  one  section  of  a  silver  catheter.  One  of  these  speci- 
mens has  been  lost,  one  was  destroyed  by  the  patient, 
three  are  now  in  the  Army  and  Navy  Medical  Museum, 
and  the  other  four  are  herewith  presented. 

I  also  wish  to  report  a  case  in  which  I  acted  as  his 
assistant.    As  soon  as  the  stone  was  caught  in  the  blades 

283 


THE  URINARY  BLADDER 


of  the  lithotrite  and  subjected  to  pressure,  it  flew  to 
pieces  as  if  it  were  glass.  The  operation  of  lithotrity 
was  at  once  abandoned  and  the  bladder  opened  above  the 
pubes.  The  fragments  of  the  stone  were  gently  removed 
with  the  finger  and  were  found  to  have  razor-like  edges, 
which  would  undoubtedly  have  seriously  injured  the  walls 
of  the  viscus  had  the  first  operation  been  continued. 

Conclusion. — For  fear  of  being  misunderstood,  per- 
mit me  to  repeat  the  views  I  maintain  in  regard  to  the 
two  operations.  I  do  not  condemn  the  crushing  opera- 
tion, for  I  believe  it  is  the  best  method  to  employ  in  cer- 
tain cases.  What  I  do  condemn  is  the  abuse  of  the 
operation  by  the  efforts  of  its  advocates  to  substitute 
it  for  the  cutting  operation  in  cases  for  which  it  is  not 
suited.  As  previously  stated,  I  believe  that  lithotomy 
should  be  the  operation  most  frequently  employed,  and 
lithotrity  reserved  for  a  few  carefully  selected  cases. 


284 


Extra-Peritoneal    Implantation    of    the 

Ureters  Into  the  Rectum  in  a  Case 

of  Exstrophy  of  the  Bladder  * 

Exstrophy  of  the  bladder  is  a  congenital  abnormality 
due  to  failure  of  the  ventral  plates  forming  the  anterior 
abdominal  wall  to  unite  in  the  median  line.  As  a  result 
the  front  wall  and  roof  of  the  bladder  are  absent,  and 
its  posterior  wall,  presents  through  a  defect  in  the  ab- 
dominal parietes. 

The  irritation  of  the  exposed  mucous  membrane,  and 
the  constant  saturation  of  the  person  and  clothing  with 
urine  makes  the  condition  of  the  patient  one  of  the  great- 
est distress.  Fortunately  the  abnormality  is  not  very 
common.  Spooner  reports  only  four  cases  in  116,500 
births.  From  80  to  90  per  cent  .of  the  cases  occur  in 
males. 

Various  operations  have  been  proposed  and  executed 
for  the  relief  of  the  condition.  They  may  be  divided  into 
two  classes :  first,  those  which  attempt  to  restore  the 
anterior  portion  of  the  abdominal  wall  and  bladder  by 
plastic  work,  and  second,  those  w^hich  attempt  to  divert 
the  urine  from  the  bladder  to  some  other  organ  by  trans- 
plantation of  the  ureters.  Plastic  operations  on  the 
bladder  are  notoriously  inefficient  in  relieving  the  con- 
dition. Flaps  artfully  obtained  from  adjacent  structures 
may  replace  the  missing  anterior  wall,  but  there  is  yet 


*  Old   Dominion   Journal   of   Medicine   and   Surgery,    August, 
1909. 

28s 


EXTRA-PERITOXEAL   IMPLANTATION 

no  possibility  of  forming  a  competent  sphincter  muscle, 
which  is  so  absolutely  necessary  to  restoration  of  func- 
tion. As  a  rule,  the  more  successful  the  plastic  operation, 
the  more  distressing  the  condition  of  the- patient,  for  the 
leakage  of  urine  continues  unabated,  and  there  are  added 
symptoms  due  to  phosphatic  deposits  and  putrefactive 
changes  in  the  newly  formed  closed  cavity.  Usually  the 
space  has  subsequently  to  be  opened  in  order  to  give 
drainage  and  expose  its  interior  to  disinfection. 

Transplantation  of  the  ureters,  so  that  the  urine  will 
be  diverted  into  the  sigmoid  or  rectum  was  done  many 
years  ago,  but  for  a  time  was  practically  abandoned,  be- 
cause in  both  clinical  and  experimental  work,  the  patient 
or  animal  invariably  died  from  ascending  infection  and 
resulting  pyelitis  and  pyelonephritis. 

Tuffier,  in  1890,  concluded  from  a  careful  study  of  the 
subject  that  the  secondary  involvement  of  the  kidneys 
was  not  essentially  the  result  of  the  implantation  of  the 
ureters  into  the  bowel,  but  was  due  to  the  division  of  the 
ureter  (which  up  to  that  time  had  been  practiced),  and 
the  loss  of  the  normal  mechanism  of  the  ureteral  valves. 
The  open  end  of  the  cut  ureter  predisposed  to  the  en- 
trance of  septic  material,  and  the  inevitable  cicatricial 
contraction  of  the  new  orifices  produced  obstruction  to 
the  escape  of  urine  and  consequent  congestion  of  the 
kidneys. 

Maydl,  in  1892,  made  practical  application  of  this 
theory  and  introduced  his  operation,  which  consisted  in 
dissecting  out  the  ureters,  leaving  a  goodly  portion  of 
bladder  mucous  membrane  around  their  terminations ; 
then  opening  the  abdomen  and  implanting  the  u/eteral 
valves  into  the  sigmoid  flexure  of  the  colon. 

286 


Fig.  8    Catheterization  of  the  Ureters  and  Beginning 
Separation  of  the  Bladder.     (Annals  of  Surgery.) 


OF  THE  URETERS  IXTO  THE  RECTUM 

Bergerhem  later  modified  the  operation  so  that  it  ac- 
complished the  same  object  without  opening  the  peritoneal 
cavity.  He  makes  an  incision  around  each  ureteral  open- 
ing and  pushes  aside  the  adjacent  tissue  until  an  inch 
or  more  of  the  ureter  hangs  free  with  a  rosette  of  mucous 
membrane  at  its  tip.  He  next  introduces  a  finger  into 
the  rectum  and  presses  it  upward  and  forward.  He 
then  dissects  through  the  openings  made  in  the  bladder 
by  the  excision  of  the  ureteral  orifices  until  he  reaches 
the  anterior  wall  of  the  rectum  and  this  is  now  opened. 
A  forceps  is  carried  through  the  anus  and  its  point  pushed 
through  the  incision  in  the  bladder.  The  ends  of  the 
ureters  are  caught,  drawn  gently  downward  into  the 
rectum  and  fastened  with  one  or  two  stitches. 

Buchanan  publishes  a  valuable  paper  on  the  "Remote 
Results  of  Implantation  of  the  Ureters  into  the  Bowel 
for  Exbtrophy,"  in  which  he  tabulates  all  recorded  opera- 
tions. Maydl's  operations  has  been  done  80  times  with 
2^  deaths,  a  mortality  of  28.'/  per  cent. ;  and  Bergen- 
hem's  operation  has  been  done  26  times  with  3  deaths, 
a  mortality  of  11.5  per  cent.,  the  striking  difference  being 
largely  due  to  the  extra-peritoneal  nature  of  the  latter 
method. 

Buchanan's  investigation  with  reference  to  the  remote 
mortality  from  ascending  urinary  infection  in  cases  sur- 
viving intestinal  implantation  of  intact  ureters  with  part 
of  the  bladder  wall  attached,  shows  that  in  98  instances 
there  have  been  only  11  deaths. 

Berger  has  traced  the  histories  of  74  cases  of  exstrophy 
of  the  bladder  not  operated  on  and  of  these,  49  died  be- 
fore the  twentieth  year  from  renal  infection.  In  compar- 
ing the  remote  death  rate  from  pyelo-nephritis  after  oper- 

287 


EXTRA-PERITOXEAL   IMPLANTATION 

ation,  (ii.2%)  with  deaths  from  the  same  cause  in  cases 
not  operated  on  (66.2%),  it  must  be  remembered  that 
many  of  the  operative  cases  suffered  with  infection  be- 
fore operation,  and  hence  surgery  should  not  always  be 
charged  with  the  development  of  fatal  complications. 

Moynihan  reports  an  operation  for  exstrophy  done  on 
a  youth  19  years  of  age,  in  which  he  transplanted  practi- 
cally the  entire  bladder  into  the  rectum  without  opening 
the  peritoneum.  The  object  of  grafting  such  a  large 
area  of  bladder  was  to  increase  the  capacity  of  the  rectum, 
and  to  form  a  cloaca  or  pouch  in  its  anterior  wall  to  act 
as  a  reservoir  for  urine.  The  operation  appears  so  logical 
and  the  results  reported  were  so  satisfactory  that  I  de- 
termined to  try  the  method  at  the  first  opportunity.  I 
herewith  report  a  recent  case,  illustrating  the  steps  of 
operation  with  the  cuts  from  Mr.  Moynihan's  original 
article  made  available  by  the  courtesy  of  the  publisher 
of  The  Annals  of  Surgery. 

F.  H.,  male,  4^/2  years,  from  Winston-Salem,  N.  C,  was  ad- 
mitted to  the  Virginia  Hospital,  January  5,  1909.  The  boy  was 
bright  and  intelligent,  but  poorly  developed  physically.  He  had 
a  typical  case  of.  exstrophy,  the  trigone  and  posterior  walls  of 
the  bladder  protruding  as  a  red  area  of  mucous  membrane 
through  a  deficiency  in  the  hypogastric  region  about  twice  the 
size  of  a  silver  dollar.  The  ureteral  orifices  showed  on  well 
marked  papillae.  They  contracted  rhythmically  and  ejected 
characteristic  spurts  of  urine.  The  lining  of  the  bladder  was 
red  and  engorged,  and  the  surrounding  skin  irritated  and  in- 
flamed from  the  leakage  of  urine.  The  penis  was  dwarfed  and 
grooved  on  its  upper  surface,  and  the  symphysis  pubis  and 
umbilicus  were  absent.  The  testicles  were  both  present  in  the 
scrotum.  After  a  week's  preparation  the  operation  to  be  de- 
scribed was  performed  in  a  clinic  before  the  students  of  the 
University  College  of  Medicine. 

288 


Fig.  8— The  Bladder  Separated  and  Rectum  Exposed. 
(Annals  of  Surgery.) 


OF  THE  URETERS  INTO  THE  RECTUM 

The  boy  was  anesthetized  with  chloroform  and  placed  in  the 
Trendelenburg-  position.  Ureteral  catheters  were  inserted  into 
each  ureter  for  a  distance  of  four  inches.  A  circular  incision 
was  made  around  the  bladder  at  its  junction  with  the  skin,  and 
it  was  dissected  from  the  underlying  tissue  until  it  hung  free 
except  for  the  two  ureters.  The  peritoneum  was  not  opened. 
The  bladder  was  wrapped  in  moist  gauze,  placed  to  one  side, 
and  all  bleeding  carefully  arrested  in  the  cavity  from  which  it 
had  been  removed.  The  sphincter  ani  was  stretched,  an  assist- 
ant's finger  introduced  into  the  rectum,  and  the  anterior  wall 
made  to  bulge  into  the  wound.  A  longitudinal  incision  was  then 
made  into  the  rectum  and  the  edges  of  the  incision  caught  with 
Volsella  forceps  and  separated.  The  bladder  was  then  rotated 
so  that  its  upper  margin  became  its  lower,  and  its  mucus  sur- 
face faced  the  cavity  of  the  rectum.  The  ends  of  the  ureteral 
catheters  were  drawn  into  the  rectum  and  out  of  the  anus.  The 
margin  of  the  bladder  was  then  carefully  sutured  with  catgut 
to  the  edges  of  the  incision  in  the  rectum.  The  abdominal 
wound  was  lightly  packed  with  gauze,  and  the  patient  returned 
to  bed  in  good  condition.  Within  two  hours  after  the  operation, 
urine  was  draining  from  both  ureteral  catheters.  The  next  day 
the  patient  pulled  one  of  the  catheters  out,  and  after  this  urine 
was  passed  both  from  the  rectum  and  from  the  remaining 
catheter  until  the  latter  was  removed.  The  boy  did  well  until 
the  fifth  day,  when  he  developed  broncho-pneumonia  and  was 
seriously  ill.  His  recovery  from  this  complication  was  due  to 
the  skillful  and  untiring  care  of  my  colleague.  Dr.  McGuire 
Newton. 

At  no  time  was  there  any  perceptible  leakage  of  urine  or  feces 
into  the  abdominal  wound.  It  rapidly  filled  with  granulation 
tissue  and  in  three  weeks  was  completely  healed  and  the  patient 
well. 

Owing  to  the  dilation  of  the  sphincter  ani,  there  was  inconti- 
nence of  faeces  for  some  days;  soon,  however,  the  muscle 
regained  its  tonicity.  Six  weeks  after  the  operation,  the  patient's 
mother  wrote  me  that  he  was  able  to  retain  his  urine  for  a 
period  of  three  hours  during  the  day  and  five  hours  during  the 
night.     Six  months   after  the  operation   she  reports  that  there 

289 


EXTRA-PERITONEAL  IMPLANTATION 

was  continued  improvement  in  urinary  control,  together  with  a 
most  decided  change  for  the  better  in  his  general  health. 

Note. — Five  years  after  operation  father  reports  that  the 
patient  is  strong  and  well.  He  goes  to  school  regularly,  and  is 
able  to  retain  urine  without  leakage  as  long  in  his  rectum  as 
other  children  do  in  their  bladders. 


290 


Intestinal    Obstruction    from    Meckel's 
Diverticulum  * 

Whether  admitted  or  not,  there  is  undoubtedly  a  gen- 
eral belief  among  surgeons  that  cases  occur  in  groups ; 
and  I  confess  the  superstition  has  been  brought  home  to 
me  by  three  cases  of  intestinal  obstruction,  due  to 
Meckel's  diverticulum,  that  have  recently  occurred  in  my 
practice.  The  symptoms,  pathologic  conditions  and  final 
results  were  so  similar  in  all  that  it  is  unnecessary  to 
give  a  separate  history  of  each.  All  were  men  between 
twenty  and  thirty  years  of  age;  all  were  taken  with  sud- 
den abdominal  pain,  followed  by  obstruction,  distention 
and  peritonitis ;  all  were  brought  to  the  hospital  practi- 
cally moribund  from  sepsis;  all  were  diagnosticated  as 
fulminating  appendicitis;  all  were  operated  upon,  and  all 
died. 

In  each  case,  when  the  abdomen  was  opened,  there 
was  the  escape  of  a  quart  or  more  of  bloody  serum;  in 
each  the  bowels  were  inflamed  and  distended  with  gas, 
and  in  each  a  gangrenous  diverticulum  was  found,  origi- 
nating from  the  ileum,  extending  upward  and  inward  to 
be  attached  by  its  tip  to  the  mesentery,  and  having  be- 
neath it  an  incarcerated  coil  of  small  intestine.  The 
specimen  I  exhibit  was  removed  from  the  last  case. 
It  is  7  inches  in  length,  one  inch  in  its  smallest  diameter 
and  is  expanded  at  its  tip  into  a  sacculated  cavity. 


*  Read   at   meeting  of   the   Richmond   Academy   of   Medicine 
and   Surgery,   January   12,    1904. 

291 


INTESTINAL  OBSTRUCTION 


The  rapidity  with  which  a  strangulated  diverticulum 
kills,  and  the  necessity  of  surgical  intervention  even  more 
prompt  than  in  appendicitis,  has  led  me  to  study  the 
available  literature  on  the  subject  and  to  report  the  rather 
unsatisfactory  result. 

In  early  fetal  development  the  intestinal  canal  com- 
municates with  the  vitelline  sac  by  means  of  the  vitelline 
or  omphalo-mesenteric  duct.  This  duct  begins  at  the 
lower  part  of  the  ileum  and  passes  through  the  abdominal 
wall  at  the  site  of  the  future  umbilicus.  It  usually  be- 
comes obliterated  at  the  end  of  the  sixth  week.  If  it 
does  not  undergo  atrophy  a  diverticulum  results  shaped 
like  a  glove  finger,  with  its  base  opening  into  the  bowel 
and  its  tip  either  floating  free  in  the  abdominal  cavity 
or  attached  by  a  fibrous  cord  to  the  umbilicus.  Meckel's 
diverticulum  varies  in  length  from  one  to  ten  inches,  and 
in  diameter  from  a  scarcely  permeable  tube  to  a  pro- 
trusion the  caliber  of  the  small  intestine.  It  is  usually 
cylindrical  in  shape,  but  may  be  sacculated  or  expanded 
into  cavities.  The  distal  extremity  may  be  smooth  and 
tapering  or  it  may  be  rough  and  bulbous.  It  is  usually 
located  about  three  feet  above  the  ileo-cecal  valve  on  the 
convex  side  of  the  intestine  opposite  the  insertion  of  its 
mesentery. 

If  free,  the  distal  end  may  become  adherent  to  any  place 
within  the  abdominal  cavity  which  its  length  permits  it  to 
reach.  Its  most  frequent  point  of  attachment  is  the  mes- 
entery, although  a  case  is  reported  where  it  was  fastened 
to  the  bladder. 

When  Meckel's  diverticulum  is  connected  with  the  um- 
bilicus by  a  fibrous  cord  it  may  cause  intestinal  obstruc- 
tion by  a  loop  of  bowel  becoming  twisted  around  it.  When 

292 


Fig.  10     Rectum  Opened  Ready  for  the  Transplantation  of 
the  Bladder.      (Annals  of  Surgery.) 


FROM   MECKEL'S   DIVERTICULUM 

it  floats  free  in  the  abdominal  cavity  it  may  cause  ob- 
struction either  by  encircUng  a  bowel  and  becoming  me- 
chanically locked  by  its  club  shaped  extremity,  or  by  the 
free  end  becoming  attached  to  a  fixed  point  by  inflamma- 
tory adhesions  and  a  loop  of  intestines  being  caught  be- 
neath it. 

Meckel's  diverticulum  is  said  to  exist  in  about  2  per 
cent,  of  all  bodies  examined.  I  have  accidentally  ob- 
served its  presence  several  times  while  operating  for 
other  abdominal  troubles.  As  the  victim  of  the  abnor- 
mality usually  goes  through  life  unconscious  of  its  exist- 
ence, and  as  only  a  small  per  cent,  have  intestinal  ob- 
struction, the  number  of  cases  reported  is  not  large. 

The  symptoms  due  to  strangulation  by  the  diverticulum 
are  sudden  in  onset.  Pain  is  severe  and  persistent  and 
referred  chiefly  to  the  region  of  the  umbilicus.  Vomiting 
appears  early  and  may  become  stercoraceous ;  tenesmus 
and  discharge  of  blood  from  the  rectum  are  absent ;  con- 
stipation is  as  a  rule  absolute ;  the  abdominal  wall  is  not 
rigid  but  later  becomes  tense  from  distension ;  fever  and 
the  attending  symptoms  of  sepsis  begin  wath  the  develop- 
ment of  peritonitis,  and  sometimes  there  is  tenderness 
or  a  perceptible  swelling  near  the  umbilicus. 

All  writers  admit  that  it  is  impossible  to  make  a  posi- 
tive diagnosis  in  a  case  of  intestinal  obstruction  due  to 
the  diverticulum,  or  to  differentiate  it  from  intestinal 
paresis  due  to  peritonitis  of  appendicular  origin ;  hence 
the  importance  of  early  operative  intervention  in  doubtful 
cases. 

Ochsner's  method  of  treatment  of  peritonitis  would 
prove  uniformly  fatal  in  mechanical  obstruction. 
The  abdomen  should    be    opened    in    the    middle    line 

293 


INTESTINAL  OBSTRUCTION 


and  the  lower  right  quadrant  first  examined.  If 
there  is  a  large  quantity  of  bloody  serum  free  from 
the  admixture  of  pus  a  strangulated  diverticulum 
will  most  likely  be  found.  As  soon  as  it  is  located 
the  tip  should  be  separated  from  the  tissue  to  which  it 
has  become  adherent  and  the  obstruction  relieved.  The 
patency  of  the  bowel  should  then  be  demonstrated  and 
its  walls  carefully  examined  to  see  if  they  are  damaged 
sufficiently  to  necessitate  resection.  Finally  the  diver- 
ticulum should  be  removed.  If  it  is  small,  it  may  be  tied 
and  amputated  like  an  appendix,  the  stump  being  buried 
or  covered  with  peritoneum.  If  it  is  large  it  would  be 
unsafe  to  trust  to  a  ligature,  as  it  might  cut  through  and 
cause  death  from  peritonitis  at  a  time  when  the  patient 
was  regarded  as  out  of  danger.  If  the  size  of  the  diver- 
ticulum approaches  that  of  the  ileum,  from  which  it 
originates,  it  should  be  amputated  and  the  opening  closed 
with  the  same  care  and  by  the  same  methods  as  an  in- 
testinal wound  of  the  same  size  from  other  causes. 


294 


Fig.  11  -The  Transplantation  Completed. 
(Annals  of  Surgery.) 


Obstruction    of    the    Esophagus,    With 
Report  of  Illustrative  Cases* 

Obstruction  of  the  esophagus  from  accident  or  disease 
is  sufficiently  common  to  make  the  subject  one  of  interest 
to  every  physician  and  surgeon.  The  cause  of  obstruction 
may  usually  be  classified  under  one  of  the  following  head- 
ings :  I,  Foreign  bodies,  2,  Spasm,  3,  Stricture,  4,  Angu- 
lation, 5,  Carcinoma.  The  diagnosis  in  an  individual  case 
is  based  on  the  history  and  symptoms  of  the  patient ;  the 
use  of  sounds,  bougies  and  the  esophagoscope ;  and  last 
but  not  least  on  the  result  of  an  X-ray  examination.  I 
desire  briefly  to  report  eight  cases  of  esophageal  obstruc- 
tion that  have  occurred  in  my  practice.  They  have  been 
selected  from  a  fairly  large  series  because  they  illustrate 
various  types  of  the  condition  and  different  methods  of 
treatment. 

I.  Obstruction  from  Foreign  Bodies. — The  first  three 
cases  represent  obstruction  due  to  the  impaction  of  a 
foreign  body.  This  accident  is  most  frequently  met  with 
in  the  very  young  and  in  the  insane.  The  foreign  bodies 
are  usually  pins,  coins,  buttons,  pieces  of  bone  or  arti- 
ficial teeth.  The  points  of  impaction  correspond  to  the 
level  of  the  upper  border  of  the  cricoid  cartilage,  or 
where  the  esophagus  is  crossed  by  the  left  bronchus,  or 
where  it  passes  through  the  diaphragm. 

The  symptoms  are  nausea,  sensation  of  obstruction, 


*Read   at   Tri-State   Medical   Association,    Charleston,    S.   C, 
February  17,  191 5. 

295  ... 


OBSTRUCTION  OF  THE  ESOPHAGUS 

pain  and  difficulty  on  swallowing,  eructation  of  food 
and  mucous,  sometimes  hemorrhage,  and  occasionally 
a  reflex  cough.  In  regard  to  prognosis  the  size  of 
the  foreign  body  is  not  as  important  as  the  shape.  If 
large  it  may  produce  complete  obstruction,  but  this  con- 
dition forces  the  patient  to  seek  prompt  reUef.  If  ir- 
regular or  sharp  pointed  the  patient  may  be  able  to  swal- 
low soft  food  and  hence  not  recognize  the  urgency  of 
the  condition  until  ulceration  of  the  esophageal  wall  leads 
to  perforation  and  the  involment  of  the  pleura  or  medi- 
astinum. 

The  character  and  location  of  the  foreign  body  being 
determined,  the  practical  question  is  how  best  to  remove 
it.  The  hypodermic  injection  of  apomorphia  has  been 
successful  in  some  cases,  but  vomiting  usually  wedges  the 
foreign  body  in  more  tightly  and  the  use  of  emetics  in 
this  class  of  cases  is  as  dangerous  and  unsurgical  as  the 
use  of  purgatives  in  intestinal  obstruction. 

If  the  foreign  body  is  round  or  smooth,  efforts  should 
be  made  to  extract  it  through  the  esophagoscope  by  means 
of  forceps  or  probangs.  If  the  body  is  soft,  and  there 
is  no  stricture  in  the  esophagus,  it  may  be  practicable  to 
push  it  into  the  stomach.  Neither  of  these  expedients 
should  be  tried,  however,  if  the  foreign  body  is  pointed, 
sharp  or  angular.  Here  under  modern  surgical  technique 
an  open  operation  is  the  safest  procedure. 

There  are  two  methods  of  approach :  by  an  external 
esophagotomy  or  by  a  gastrotomy,  and  the  selection  of 
the  route  will  depend  on  the  location  of  the  impaction. 
If  it  is  opposite  the  cricoid  cartilage  an  esophagotomy 
should  be  done.  If  it  is  below  the  level  of  the  supra- 
clavicular notch  a  gastrotomy  should  be  performed. 

296 


WITH  REPORT  OF  ILLUSTRATIVE  CASES 

Case  I,  D.  C,  male,  aged  sixteen  years,  was  a  patient  at  the 
Virginia  Hospital.  Five  days  before  admission,  the  boy  sneaked 
into  a  kitchen  and  grabbed  a  hunk  of  meat.  He  was  pursued  by 
the  cook,  crammed  the  meat  into  his  mouth  and  attempted  to 
swallow  it.  The  bolus  lodged  in  his  esophagus  and  the  obstruc- 
tion could  be  located  with  a  bougie  just  above  the  cardiac  open- 
ing of  the  stomach.  The  patient  had  been  unable  to  take  either 
liquids  or  solids  and  was  suffering  horribly  from  thirst.  As 
there  was  no  stricture  of  the  esophagus,  and  as  the  impacted 
body  was  soft,  a  stiff  bougie  was  inserted  and  steady  pressure 
made,  when  the  bolus  was  felt  to  pass  into  the  stomach.  The 
patient  was  given  a  glass  of  water,  but  was  at  first  incredulous 
as  to  his  ability  to  swallow.  When  the  first  gulp  went  down  his 
expression  of  pleasure  was  ludicrous,  and  he  drank  glass  after 
glass  until  he  had  swallowed  a  quart  or  more. 

Case  2,  M.  S.,  female,  aged  ten  years,  patient  at  St.  Luke's 
Hospital,  gave  history  of  putting  the  glass  stopper  of  a  cologne 
bottle  in  her  mouth  and  swallowing  it.  The  stopper  lodged  in 
the  esophagus  opposite  the  cricoid  cartilage  and  produced  com- 
plete obstruction.  Eight  days  later  she  was  brought  to  the  hos- 
pital in  a  pitiable  condition  from  thirst  and  starvation.  A  throat 
specialist  was  called  in  consultation,  but  despite  patient  and  skill- 
ful efforts  he  failed  to  remove  it.  It  was  then  decided  to  do  an 
external  esophagotomy.  The  patient  was  anesthetized  and  a 
three  inch  incision  was  made  on  the  left  side  of  the  neck  parallel 
with  the  anterior  border  of  the  sterno-mastoid  muscle.  The 
deep  cervical  fascia  was  exposed  and  divided.  The  thyroid, 
larynx  and  trachea  were  pulled  forward  and  the  large  vessels 
and  the  nerves  backward,  thus  exposing  the  esophagus.  A  large 
bougie  was  then  passed  to  the  point  of  obstruction  and  the 
esophagus  incised  on  its  tip.  The  glass  stopper  at  once  came 
into  view  and  was  easily  removed. 

Case  3,  L.  K.,  baby,  aged  seven  months,  was  a  patient  at  the 
Virginia  Hospital.  The  baby  while  being  dressed  had  seized  an 
open  safety  pin  and  put  it  in  his  mouth.  The  mother  in  her 
endeavor  to  remove  it,  pushed  it  first  into  the  fauces  and  then 
into  the  esophagus.  The  family  physician  and  later  a  throat 
specialist  made  unsuccessful  efforts  to  remove  it  with  probangs. 

297 


OBSTRUCTION  OF  THE  ESOPHAGUS 

Five  weeks  after  the  accident  the  child  was  brought  to  the  Vir- 
ginia Hospital.  He  was  feverish,  emaciated  and  evidently  in 
constant  pain.  A  skiagram  located  the  pin  in  the  esophagus 
immediately  behind  the  heart.  The  safety  pin  was  open  with 
the  point  up  and  it  was  evidently  impossible  to  remove  it  from 
above.  It  was  therefore  determined  to  do  a  gastrotomy  and 
extract  it  from  below.  The  patient  was  anesthetized  and  the 
abdomen  opened.  The  stomach  was  incised  and  a  finger  inserted 
and  carried  through  the  cardiac  opening.  At  first  the  pin  could 
not  be  reached,  but  by  the  use  of  an  esophageal  bougie  passed 
from  above  it  was  pushed  into  a  position  to  be  easily  removed. 

II.  Obstruction  from  Spasm. — The  next  case  illus- 
trates obstruction  of  the  esophagus  from  spasm.  By  this 
is  not  meant  esophagismus  but  cardiospasm.  Esopha- 
gismus  is  a  paroxysmal  contraction  of  the  upper  part  of 
the  esophagus,  seen  in  smokers,  drinkers  and  hysterical 
individuals,  which  is  a  functional  disease  and  unattended 
by  organic  changes.  Cardiospasm  is  a  more  or  less  con- 
stant contraction  of  the  cardiac  opening  of  the  stomach 
producing  an  obstruction  which  results  in  organic  changes 
such  as  hypertrophy  of  muscles,  dilatation  and  saccula- 
tion of  the  esophagus  and  inflammation  and  ulceration 
of  the  mucous  membrane.  The  term  cardiospasm  is  an 
unfortunate  one,  for  when  seen  or  heard  for  the  first 
time  it  is  often  thought  to  refer  to  some  disease  of  the 
heart.  The  true  significance  of  the  term  will  be  im- 
pressed if  it  is  remembered  that  the  stomach  has  two 
openings,  the  pyloric  and  the  cardiac,  and  that  pyloro- 
spasm  is  spasm  of  the  one  and  cardiospasm  is  spasm  of 
the  other. 

The  etiology  of  pylorospasm  has  been  settled  and  it 
is  known  that  it  is  a  protective  effort  on  the  part  of  nature 
to  prevent  the  passage  of  irritating  gastric  contents  into 

298 


WITH  REPORT  OF  ILLUSTRATIVE  CASES 

the  intestinal  canal.  It  is  a  symptom  and  not  a  disease 
and  is  commonly  seen  in  cases  of  chronic  appendicitis, 
cholecystitis  and  ulcer  of  the  duodenum. 

The  etiology  of  cardiospasm  is  undetermined.  There 
are  many  theories  but  it  would  not  be  profitable  to  discuss 
them  here,  as  they  are  unsubstantiated  and  contradictory. 
The  condition  was  formerly  thought  to  be  rare,  but  it  is 
now  being  recognized  with  increasing  frequency,  the  ac- 
curacy of  the  diagnosis  being  demonstrated  by  the  result 
of  treatment. 

Patients  with  cardiospasm  are  usually  thought  to  suf- 
fer from  some  disease  of  the  stomach.  The  symptoms 
often  cover  a  period  of  many  years  but  vary  in  intensity 
at  diflFerent  times.  They  consist  of  a  sensation  of  press- 
ure and  fullness  after  eating  relieved  by  vomiting.  The 
regurgitation  of  food  is  accomplished  with  little  effort 
and  without  nausea.  The  material  spit  up  may  be  one 
or  two  pints  in  quantity,  and  consists  of  mucous  and  un- 
digested food  without  trace  of  hydrochloric  acid  or  pep- 
sin. If  a  stomach  tube  is  introduced  a  short  way  into  the 
esophagus  there  is  the  escape  of  fluid  through  its  lumen 
and  along  its  sides.  When  the  tube  reaches  the  cardiac 
opening  of  the  stomach  an  obstruction  is  met  which  is 
overcome  by  moderate  pressure  continued  for  a  short 
time.  If  after  emptying  the  esophagus  the  patient  will 
drink  a  mixture  of  bismuth  and  buttermilk  a  skiagram  of 
the  chest  will  show  the  shadow  of  the  dilated  esophagus 
with  perhaps  a  small  stream  of  bismuth  mixture  trickling 
into  the  stomach  through  the  spasmodic  stricture  at  the 
cardia. 

The  treatment  of  this  condition  was  formerly  very  un- 
satisfactory.    Its  cure  is  now  simple,  safe,  prompt  and 

299 


OBSTRUCTION  OF  THE  ESOPHAGUS 

permanent.  At  first  antispasmodics  and  other  drugs  were 
tried  without  success.  Then  resort  was  Had  to  surgery. 
MikuHcz  operated  on  and  cured  six  patients  by  opening 
the  abdomen,  incising  the  stomach  and  forcibly  dilating 
the  cardiac  opening.  The  result  in  this  series  established 
the  principle  for  successful  treatment  and  future  effort 
was  made  to  devise  a  means  by  which  the  spasmodic 
stricture  could  be  efficiently  stretched  without  opening 
the  abdomen. 

This  problem  has  been  satisfactorily  met  by  Plummer's 
Hydrostatic  Dilator  which  consists  essentially  of  an  eso- 
phageal bougie  with  a  collapsible  rubber  bag  at  its  tip. 
After  the  bougie  has  been  passed  through  the  stricture  the 
bag  is  distended  with  water  and  the  desired  degree  of 
dilatation  exerted  by  slowly  increasing  the  amount  of 
fluid  until  the  attached  metre  shows  the  requisite  number 
of  pounds  pressure.  After  one  or  two  treatments  the 
spasm*  disappears,  the  symptoms  are  relieved  and  the 
patient  gains  weight  and  strength  in  a  marvelous  way. 

Case  4,  S.  H.,  male,  aged  sixty-one,  was  a  patient  at  St.  Luke's 
Hospital.  He  stated  that  for  the  last  ten  or  twelve  years  he  had 
had  trouble  in  swallowing.  His  appetite  was  normal  but  food 
would  not  go  into  the  stomach.  After  eating  he  suffered  pain 
and  oppression  and  then  the  food  either  slowly  entered  the 
stomach  or  was  vomited.  His  trouble  had  recently  grown  much 
worse  and  he  now  spit  up  practically  all  the  food  he  took.  He 
had  lost  twenty-five  pounds  in  weight  and  had  become  more  or 
less  nervous  and  despondent.  A  stomach  tube  was  inserted  and 
readily  pased  down  the  esophagus  until  it  reached  the  cardiac 
end  where  it  met  an  obstruction.  Gentle  pressure  was  made  and 
in  a  few  moments  the  obstruction  yielded  and  the  tube  entered 
the  stomach.  An  X-ray  examination  after  a  bismuth  meal  showed 
the  esophagus  full  of  fluid  which  was  trickling  drop  by  drop 
through  the  cardiac  opening  into  the  stomach.  A  diagnosis  of 
cardiospasm  was  made,  and  the  patient  was  treated  with  Plum- 
mer's hydrostatic  dilators.     After  being   dilated   three  or   four 

300 


Fig.  12— Obstruction  of  Esophagus  Caused  by  Cardiospasm. 


WITH  REPORT  OF  ILLUSTRATIVE  CASES 

times  he  was  able  to  swallow  without  diffifficulty,  and  one  year 
later  reported  that  he  had  gained  thirty  pounds  in  weight  and 
was  perfectly  well. 

III.  Obstruction  from  Stricture. — The  next  two  cases 
illustrate  obstruction  of  the  esophagus  from  organic 
stricture,  one  the  result  of  swallowing  concentrated  lye, 
the  other  the  result  of  a  severe  attack  of  typhoid  fever. 
The  most  common  causes  of  stricture  of  the  esophagus 
are  syphilis,  the  local  action  of  mechanical,  chemical  or 
thermal  irritants  and  the  remote  resuhs  of  certain  acute 
infectious  diseases  such  as  typhoid  fever,  scarlet  fever, 
diphtheria  and  smallpox. 

When  due  to  syphilis,  the  stricture  is  usually  in  the 
upper  part  of  the  esophagus  and  is  of  large  calibre.  The 
diagnosis  is  based  on  the  history,  presence  of  other  lesions 
and  on  the  Wasserman  test.  Stricture  due  to  local  irri- 
tants or  toxic  diseases  are  usually  located  near  the  car- 
dia,  and  are  diagnosed  by  the  history  and  symptoms  of 
the  patient,  and  the  use  of  the  bougie,  esophagoscope 
and  X-ray.  The  treatment  of  esophageal  stricture  con- 
sists in  either  bloodless  or  operative  dilatation.  The  ex- 
pedients which  have  been  employed  to  correct  the  con- 
dition are  ingenious  and  interesting,  but  too  varied  and 
numerous  to  be  described.  If  the  case  is  seen  sufficiently 
early  it  is  usually  possible  to  effect  a  cure  by  gradual 
dilatation  with  bougies  or  sounds.  The  treatment  re- 
quires skill  and  patience  and  has  to  be  kept  up  for  months 
or  years.  In  some  cases  where  the  stricture  is  found 
impermeable,  or  where  the  patient's  condition  requires 
prompt  reUef,  the  abdomen  has  to  be  opened,  a  gastro- 
tomy  performed  and  the  stricture  divided  by  Abbe's  or 
some  other  method. 

301 


OBSTRUCTION  OF  THE  ESOPHAGUS 

Case  5,  A.  B.,  male,  aged  two  years,  was  a  patient  at  St.  Luke's 
Hospital.  Some  months  before,  the  child  in  crawling  about  the 
floor  found  a  saucer  containing  concentrated  lye  that  had  been 
used  to  remove  grease  spots,  and  as  babies  usually  do  when  in- 
vestigating new  objects,  he  put  some  of  the  lye  in  his  mouth  and 
swallowed  it.  The  symptoms  of  stricture  soon  followed.  On 
admission  the  patient  could  only  take  a  few  drops  of  milk 
at  a  time  and  was  nearly  dead  from  starvation.  After  long 
effort  under  chloroform  anesthesia  a  very  small  bougie  was 
finally  passed  through  the  stricture.  A  progressively  larger  sized 
bougie  was  introduced  at  intervals  of  several  days  and  this  treat- 
ment continued  for  some  weeks.  The  child  was  then  sent  home 
with  instruction  to  bring  him  back  at  stated  intervals  for  obser- 
vation and  treatment.  This  was  faithfully  done  by  the  parents 
who  fortunately  did  not  live  at  a  great  distance.  When  the 
patient  was  about  six  years  old  the  father  was  told  that  it  was 
unnecessary  to  continue  the  administration  of  choloform  in  order 
to  pass  the  bougie.  He  hesitated  a  moment  and  then  said  "Please 
give  it  to  him  twice  more  as  that  will  be  one  hundred  times  he 
will  have  taken  it  and  some  day  he  will  be  proud  to  tell  about 
it."  The  boy  is  now  ten  years  old  and  is  apparently  completely 
well. 

Case  6,  H.  B.  R.,  male,  aged  22,  was  a  patient  at  St  Luke's 
Hospital.  Four  months  before  admission  he  was  taken  with 
typhoid  fever  and  confined  to  bed  for  seven  weeks.  During  the 
last  ten  days  he  was  in  bed  he  noticed  a  progressively  increas- 
ing difficulty  in  swallowing  liquids,  and  when  he  was  finally 
given  permission  to  eat  solid  food  he  found  that  the  food  would 
not  pass  into  the  stomach,  but  lodged  in  the  esophagus,  where  it 
remained  until  he  either  vomited  or  gulped  it  up.  An  esophageal 
bougie  showed  an  obstruction  three  or  four  inches  above  the 
stomach.  An  X-ray  plate  made  after  drinking  a  mixture  of 
bismuth  and  buttermilk  showed  a  stricture  of  small  calibre  and 
about  three  inches  in  length  at  the  lower  end  of  the  esophagus. 
Efforts  at  dilatation  on  three  successive  days  failed,  but  finally 
a  small  bougie  was  passed.  The  stricture  was  slowly  but  steadily 
dilated.    The  patient  remained  in  the  Hospital  eighteen  days  and 

302 


Fig.  13— Obstruction  of  the  Esophagus  Due  to  Stricture  the 
Result  of  Typhoid  Fever. 


WITH  REPORT  OF  ILLUSTRATIVE  CASES 

gained  eighteen  pounds  in  weight.     He  was  then  sent  home  to 
hii  family  physician  to  have  the  treatment  continued. 

IV.  Obstruction  from  Angulation. — The  next  case 
illustrates  obstruction  of  the  esophagus  from  angulation 
due  to  diaphragmatic  hernia. 

Case  7,  B.  D.,  male,  aged  nineteen,  was  a  patient  at  St.  Luke's 
Hospital.  He  stated  that  four  months  before  his  admission  he 
had  been  struck  in  the  abdomen  and  knocked  down.  His  antag- 
onist then  jumped  on  him  and  cut  him  with  a  pocket  knife  on 
the  neck  and  outer  side  of  the  arm,  and  finally  stabbed  him  in 
the  left  side  of  the  chest.  For  three  days  he  was  unconscious 
and  for  three  weeks  he  could  take  no  food  by  mouth  and  had 
to  be  sustained  by  nutritive  anemas.  He  then  began  to  swallow 
liquids,  but  if  he  attempted  to  eat  solids  he  experienced  the  sen- 
sation as  though  the  food  stopped  before  it  reached  the  stomach, 
and  he  would  spit  or  vomit  it  up  shortly  afterwards.  An  at- 
tempt was  made  to  pass  a  stomach  tube,  but  it  met  with  com- 
plete block  17%  inches  from  the  incisor  teeth,  A  mixture  of 
bismuth  and  buttermilk  was  given  slowly  by  mouth  and  after 
eight  ounces  had  passed  into  the  stomach  a  skiagram  was  made, 
when  it  was  found  that  the  man  had  diaphragmatic  hernia,  and 
that  the  stomach  was  in  the  left  thoracic  cavity.  The  obstruc- 
tion in  the  esophagus  was  obviously  due  to  angulation.  The 
patient's  thorax  was  opened  by  raising  a  rectangular  flap  con- 
sisting of  the  entire  thickness  of  the  chest  wall  and  containing 
sections  of  the  eighth  and  ninth  ribs.  Adhesions  between  the  her- 
niated stomach  and  the  heart,  lung  and  pleura  were  separated, 
the  stomach  was  returned  to  the  abdominal  cavity  and  the  rupture 
of  the  diaphragm  sutured.  The  patient  made  a  rapid  recovery 
and  was  completely  relieved  of  his  previous  difficulty  in  swallow- 
ing. 

V.  Obstruction  from  Carcinoma. — The  last  case  illus- 
trates obstruction  of  the  esophagus  from  carcinoma. 

Case  8,  J.  A.,  male,  aged  fifty-nine,  was  a  patient  at  St.  Luke's 
Hospital.    The  man's  previous  history  was  negative.    The  present 

303 


OBSTRUCTION  OF  THE  ESOPHAGUS 

symptoms  had  begun  two  months  before  his  admission  and  con- 
sisted of  difficulty  in  taking  food.  If  he  swallowed  any  solid 
material  it  caused  pain  in  his  chest  and  then  in  a  few  minutes 
he  could  feel  it  enter  the  stomach  and  the  pain  was  relieved. 
During  the  last  few  weeks  he  had  been  unable  to  swallow  any 
solid  foods  and  even  liquids  remained  in  the  esophagus  and 
were  regurgitated  several  hours  after  being  swallowed.  For  the 
past  week  he  had  been  sustained  by  nutritive  enemata.  There 
was  no  history  of  syphilis,  of  acute  infectious  disease  or  of 
swallowing  a  caustic.  X-ray  showed  a  stricture  at  the  cardiac 
end  of  the  stomach.  An  esophageal  bougie  could  not  be  passed 
and  hence  an  abdominal  section  was  decided  on  in  order  to 
demonstrate  the  nature  of  the  lesion.  The  abdomen  was  opened, 
and  after  delivering  and  palpating  the  stomach,  a  hard,  annular 
growth  was  found  completely  obstructing  the  cardiac  orifice. 
As  the  disease  was  unquestionably  malignant,  a  gastrostomy  was 
done  by  Senn's  method,  and  the  patient  was  afterwards  fed 
through  the  tube  by  means  of  a  funnel.  He  gained  weight  and 
strength  in  a  most  satisfactory  way,  and  was  sent  home  in  good 
shape.  Three  months  later  he  was  found  dead  in  bed  and  it 
was  thought  it  was  probable  he  had  committed  suicide. 


304 


Fig.  14— Obstruction  of  Esophagus  Caused  by  Cancer  of  the  Cardia. 


Diaphragmatic    Hernia,    With    Report 

of  a  Case* 

Diaphragmatic  hernia  is  the  protrusion  of  one  or  more 
of  the  abdominal  viscera  into  the  pleural  cavity  through 
an  opening  in  the  diaphragm. 

The  opening  may  be  a  defect  in  development,  a  dila- 
tation of  a  normal  aperture,  or  a  rupture  due  to  trauma- 
tism. Therefore  diaphragmatic  hernias  may  be  either 
congenital  or  acquired. 

In  ten  per  cent,  of  cases  the  herniated  mass  is  enclosed 
in  a  peritoneal  sac,  but  in  ninety  per  cent,  of  cases  the 
viscera  lie  bare  in  the  pleural  cavity,  hence  in  a  strict 
sense  these  hernias  may  be  divided  into  true  and  false. 

According  to  statistics  diaphragmatic  hernia  occurs  on 
the  right  side  in  eight  per  cent,  of  cases,  and  on  the  left 
in  ninety-two  per  cent,  of  cases.  The  relative  immunity 
of  the  right  side  is  largely  due  to  the  presence  of  the 
liver  which  acts  as  a  buffer  and  protects  the  diaphragm 
on  that  side  from  the  effects  of  increased  abdominal  press- 
ure and  closses  effectively  any  rupture  that  may  occur 

The  abdominal  organs  most  frequently  found  in  a 
diaphragmatic  hernia  are  the  stomach,  colon,  small  in- 
testines and  omentum  in  the  order  named.  Almost  every 
abdominal  organ,  however,  except  the  rectum  and  pelvic 
viscera  has  been  found  in  one  or  more  of  the  cases  that 
have  been  recorded. 


*  Read  at  a  meeting  of  the  North  Carolina  State  Medical  As- 
sociation, Raleigh,  N.  C,  June,  1914. 

305 


DIAPHRAGMATIC  HERNIA, 


Diaphragmatic  hernias  are  not  common,  but  they  occur 
with  sufficient  frequency  to  make  it  necessary  to  bear 
the  condition  in  mind  when  making  a  diagnosis  in  an 
obscure  case.  At  the  time  of  the  pubHcation  of  Giffin's 
paper  in  the  Annals  of  Surgery  for  March,  1912,  six 
hundred  and  fifty  cases  had  been  reported,  but  most  of 
these  were  either  congenital  hernias  occurring  in  babies 
or  symptomless  hernias  discovered  at  autopsy.  Accord- 
ing to  Giffin,  only  fifteen  cases  of  diaphragmatic  hernia 
had  been  correctly  diagnosed  during  life. 

The  recognition  of  the  condition  is  based  on  a  careful 
inquiry  into  the  patient's  previous  history,  especially  with 
reference  to  injuries,  on  a  thorough  physical  examination 
of  the  chest,  and  on  radiographic  and  fluoroscopic  exami- 
nations after  the  ingestion  of  a  bismuth  meal.  The  con- 
ditions most  difficult  to  exclude  in  making  a  differential 
diagnosis  are  pneumothorax  and  eventration  of  the  dia- 
phragm. 

The  treatment  of  diaphragmatic  hernia  is  essentially 
surgical.  While  patients  with  the  trouble  have  been 
known  to  live  for  years,  sooner  or  later  they  all  develop 
obstructive  symptoms,  inflammatory  complications  or 
strangulation  with  gangrene. 

Two  exploratory  routes  have  been  recommended  to 
reduce  the  hernia  and  repair  the  tear  in  the  diaphragm — 
the  thoracic  and  the  abdominal.  Those  who  favor  the 
thoracic  route  claim  that  the  adhesions  can  be  more 
safely  separated,  that  the  diaphragmatic  opening  can  be 
more  easily  sutured  and  that  by  the  entrance  of  air 
into  the  pleural  cavity  the  negative  pressure  or  suction 
power  of  the  thorax  is  abolished  so  that  replacement  of 

the  viscera  is  less  difficult. 

306 


•oi^ 


WITH  REPORT  OF  A  CASE 


Those  who  favor  the  abdominal  route  claim  that  a 
considerable  number  of  hernias  can  be  reduced  without 
opening  the  thorax,  and  that  it  is  not  wise  to  collapse 
the  lung  if  it  can  be  avoided ;  also  that  the  viscera  in- 
jured from  strangulation  are  the  abdominal  organs  and 
that  they  can  be  better  repaired  through  an  abdominaJ 
incision. 

The  following  brief  quotations  from  various  authors 
will  show  the  evolution  of  surgical  opinion  on  the  sub- 
ject of  diaphragmatic  hernia  during  the  last  twenty-five 
years. 

Holmes'  System  of  Surgery,  published  in  1881,  con- 
tains the  following:  "We  are  silent  on  the  subject  of 
treatment.  We  can  not  hope  to  close  the  aperture  in  the 
diaphragm  by  any  measures  which  science  or  mechanical 
surgery  would  justify ;  could  we  accurately  detect  the 
existence  of  a  protrustion  it  were  in  vain  to  attempt  its 
reduction  with  any  benefit  to  the  patient  or  credit  to 
ourselves." 

Von  Bergmann's  Surgery,  publislied  in  1904,  states : 
"Up  to  this  time  no  radical  operation  has  ever  been  per- 
formed for  non-strangulated  hernia  in  this  region, 
although  an  operation  is  indicated  provided  the  diagnosis 
is  certain." 

Fergusson  in  his  book.  Modern  Operations  for  Hernia- 
published  in  1907,  says  :  "The  presence  of  diaphragmatic 
hernia  is  seldom  discovered  during  life.  In  but  seven 
of  the  two  hundred  and  sixty-six  cases  review^ed  by  Lach- 
ner  was  the  diagnosis  made  ante-mortem.  If  the  hernia 
is  incarcerated  I  believe  the  thoracic  route  the  preferable 
one,  but  in  a  case  where  the  hernia  is  inflamed,  ulcerated, 
strangulated  or  gangrenous  when  a  resection  of  the  bowel 

307 


DIAPHRAGMATIC  HERNIA, 


must  be  done  the  thoracic  insures  less  tendency  to  infect 
the  peritoneal  cavity." 

Ochsner  in  his  Clinical  Surgery,  published  in  191 1, 
says :  "Diaphragmatic  hernias  are  very  rare,  and  when 
they  do  exist  are  seldom  discovered  before  the  abdomen 
is  opened.  The  majority  of  cases  that  have  been  reported 
have  been  found  at  post-mortem.  Diaphragmatic  hernia 
may  be  congenital  or  acquired.  The  congenital  variety 
is  rarely  amenable  to  surgical  treatment  because  so  great 
a  portion  of  the  diaphragm  is  absent  that  it  is  impossible 
to  close  the  large  opening.  The  acquired  variety  may 
frequently  be  benefited  by  operation." 

Mumford  in  his  book  on  Practice  of  Surgery,  published 
in  191 1,  says:  "The  treatment  of  strangulated  diaphrag- 
matic hernia  is  obviously  to  open  the  abdomen  and  treat 
the  viscera  as  the  conditions  indicate.  Hitherto  no 
operation  is  reported  as  performed  upon  a  non-strangu- 
lated diaphragmatic  hernia." 

Binnie  in  his  Operative  Surgery,  published  in  1914, 
says:  "Of  the  cases  of  strangulated  diaphragmatic  her- 
nia collected  by  Neugebauer  all  those  operated  on  through 
the  abdominal  route  died ;  one  out  of  the  two  operated 
on  the  thorax  lived.  The  only  two  cases  of  non-strangu- 
lated diaphragmatic  hernia  submitted  to  radical  cure 
(Llobet's  and  Cranwell's)  lived  after  a  trans-thoracic 
operation." 

Doubtless  some  cases  of  diaphragmatic  hernia  have 
been  operated  on  and  not  reported,  and  other  cases  have 
been  operated  on  and  recorded  since  the  statistics  quoted 
were  compiled,  still  the  total  number  of  operations  is  so 
small  that  I  feel  justified  in  reporting  the  following  case: 

308 


Fig.  16— X-Ray  of  Second   Case,  Before  Operation, 
Showing  Stomach  in  Left  Thoracic  Cavity 


WITH  REPORT  OF  A  CASE 


B.  D.,  male,  aged  19;  entered  St.  Luke's  Hospital  April  10. 
1914,  referred  by  Dr.  J.  B.  Catlett,  of  Staunton,  Va.  Patient 
stated  that  four  months  ago  as  he  came  out  of  a  pool  room 
he  met  a  man  with  whom  he  had  quarreled  earlier  in  the  day, 
who  struck  him  with  great  force  in  the  epigastrium  with  a  bottle. 
The  blow  knocked  him  down  and  his  antagonist  jumped  on 
him  and  cut  him  on  the  left  side  of  the  neck,  on  the  outer  side 
of  the  left  arm,  and  finally  stabbed  him  in  the  posterior  axillary 
line  about  the  third  intercosal  space  on  the  left  side  of  the 
chest.  The  patient  bled  profusely  from  the  wounds,  vomited 
blood  and  later  passed  much  blood  by  bowel.  The  incisions  were 
sutured  without  an  anesthetic  and  the  patient  put  to  bed.  For 
three  days  he  was  unconscious.  He  finally  began  slowly  to  im- 
prove, but  for  three  weeks  he  could  take  no  food  by  mouth 
and  had  to  be  sustained  by  nutritive  enemata.  He  then  became 
able  to  swallow  and  retain  liquids.  If  he  attempted  to  eat  solids. 
however,  he  experienced  a  sensation  as  though  the  food  stopped 
before  it  reached  the  stomach,  and  he  would  spit  or  vomit  it 
up  shortly  after  swallowing  it. 

When  the  patient  was  brought  to  Richmond  he  was  very  weak 
and  anemic  and  had  lost  about  fifty  pounds  in  weight.  Physical 
examination  of  the  chest  showed  the  heart  markedly  displaced 
to  the  right  and  a  tympanitic  percussion  note  with  absence  of 
breath  sounds  from  the  fifth  rib  down  on  the  left  side.  An  at- 
tempt was  made  to  pass  a  stomach  tube,  but  it  met  with  a 
complete  block  lyy^  inches  from  the  incisor  teeth. 

A  mixture  of  bismuth  and  buttermilk  was  given  slowly  and 
after  about  eight  ounces  were  introduced  into  the  stomach  sev- 
eral radiograms  of  the  abdomen  were  made  by  Dr.  A.  L.  Gray. 
The  history,  symptoms,  physical  examination  and  X-ray  findings 
all  pointed  to  diaphragmatic  hernia,  with  escape  of  practically 
the  entire  stomach  into  the  left  thoratic  cavity. 

An  operation  was  advised  and  agreed  to.  It  was  determined 
to  adopt  the  transpleural  rather  than  the  abdominal  route,  as 
the  hernia  had  been  in  existence  for  four  months,  and  it  was 
believed  that  the  adhesions  between  the  stomach  and  the  viscera 
of  the  chest  were  so  strong  and  numerous  that  they  could  not 
be  safely  separated  except  under  direct  inspection. 

309 


DIAPHRAGMATIC  HERNIA, 


The  patient  was  placed  on  the  table  in  the  reverse  Trendelen- 
burg position  in  order  to  minimize  the  possible  shock  from  the 
sudden  admission  of  air  into  the  pleural  cavity. 

The  incision  was  made  after  the  method  suggested  by  Cran- 
well.  The  lower  and  lateral  part  of  the  thorax  was  opened 
by  a  flap  having  its  base  above,  consisting  of  the  whole  thick- 
ness of  the  chest  wall  and  containing  about  five  inches  of  the 
eighth  and  ninth  ribs.  As  soon  as  the  parietal  pleura  was  opened 
the  stomach  presented  itself.  There  were  numerous  adhesions 
between  it  and  the  pericardium  and  collapsed  left  lung.  These 
were  carefully  separated,  several  attachments  requiring  prelimi- 
nary ligature. 

A  very  dense  and  firm  adhesion  was  found  between  the  car- 
diac end  of  the  stomach  and  the  postero-lateral  surface  of  the 
chest  wall  just  opposite  the  stab  wound.  This  was  peeled  loose 
after  considerable  efifort  and  there  was  at  once  the  escape  of 
some  stomach  contents.  The  stomach  was  delivered  through 
the  opening  into  the  thorax  and  an  incision  three  inches  long 
found  on  its  anterior  surface  beginning  near  the  esophageal 
opening  and  extending  in  the  direction  of  its  greater  curvature. 
The  edges  of  this  incision  did  not  bleed  and  showed  evidences 
of  cicatrization,  hence  it  seems  reasonable  to  believe  that  the 
rupture  of  the  diaphragm  and  hernia  of  the  stomach  resulted 
from  the  blow  and  injury  inflicted  on  the  abdomen  prior  to 
the  cutting,  and  that  when  the  stab  wound  was  made  in  the 
third  intercostal  space  the  vulnerating  instrument  cut  the  stomach 
which  was  already  in  the  left  thoracic  cavity. 

The  opening  just  described  in  the  stomach  was  sutured  in 
the  usual  way,  and  then  the  adhesions  to  the  stomach  where 
it  passed  through  the  diaphragm  were  separated,  and  the  stomach 
replaced  in  the  abdomen. 

The  rupture  in  the  diaphragm  was  about  four  inches  in  length, 
beginning  near  the  esophageal  opening  and  extending  through 
the  left  leaf  toward  the  sternum.  The  tear  was  repaired  with 
two  tiers  of  chromic  catgut  sutures.  A  rubber  drain  was  then 
placed  in  the  pleural  cavity  and  the  opening  in  the  chest  wall 
closed.  The  operation  while  spectacular  was  not  difficult  and 
was  completed  in  fifty-five  minutes.     There  was  little  bleeding 

310 


Fig.  17-  Incision  in  Operation  by  Thoracic  Route. 
(Copied  from  Binnie)) 


WITH  REPORT  OF  A  CASE 


and  no  appreciable  shock.  The  patient  did  not  suffer  from 
nausea,  and  begged  for  a  cigarette  as  soon  as  he  became  con- 
scious. Liquid  nourishment  was  given  the  following  day.  At 
the  end  of  a  week  the,  patient  was  placed  on  general  diet  and 
from  the  first  swallowed  and  retained  solid  food  without 
difficulty. 

He  gained  weight  at  the  rate  of  a  pound  a  day  and  left  the 
hospital  in  four  weeks  after  the  operation.  A  radiogram  taken 
just  before  the  patient  was  dismissed  showed  the  stomach  in 
its  normal  position,  the  heart  almost  back  in  its  proper  place, 
but  the  collapsed  lung  not  yet  fully  expanded. 

Second  Case  of  Diaphragmatic  Hernia  operated  on 
after  the  above  was  published. 

R.  M.,  male,  aged  34,  entered  St.  Luke's  Hospital  November 
27,  1914,  referred  by  Dr.  W.  N.  Thomas,  of  Oxford,  N.  C. 
Patient  stated  that  seven  months  ago  while  working  on  the  roof 
of  a  house  a  rope  broke  and  he  fell  a  distance  of  thirty-four 
feet.  He  was  unconscious  for  two  hours.  On  examination  it 
was  found  that  he  had  fractured  both  bones  of  his  forearm,  in- 
jured his  left  hip  and  received  numerous  cuts  and  bruises.  He 
suffered  with  pain  and  soreness  in  the  epigastrium  and  hic- 
coughed for  three  days.  There  was  nausea  but  no  vomiting. 
Patient  was  confined  to  bed  for  six  weeks.  He  had  little  ap- 
petite and  what  he  ate  caused  distress.  When  he  finally  got  up 
and  began  to  walk,  he  noticed  a  gurgling  sound  in  his  left  chest 
similar  to  what  he  had  frequently  heard  and  felt  in  his  abdomen 
before  the  accident. 

In  July  he  came  to  Richmond  and  entered  a  hospital  in  order 
to  have  the  bones  of  his  arm  reset.  The  surgeon  in  making 
his  general  examination,  recognized  the  presence  of  a  diaphrag- 
matic hernia,  and  confirmed  his  diagnosis  by  an  X-ray  plate. 
The  patient  was  operated  on  for  the  vicious  union  of  the  bones 
of  the  forearm  but  declined  to  have  anything  done  for  the 
rupture  of  his  diaphragm.  He  returned  home,  but  suffered  so 
much  from  indigestion  and  shortness  of  breath  that  he  was 
finally  persuaded  to  come  to  me  for  surgical  relief. 

311 


DIAPHRAGMATIC  HERNIA, 


Physical  examination  showed  the  left  chest  larger  than  the 
right.  There  was  hyperresonance  from  the  fourth  rib  down, 
and  peristaltic  sounds  were  plainly  audible.  An  X-ray  plate 
made  after  a  bismuth  meal  showed  practically  the  entire  stomach 
in  the  left  pleural  cavity.  The  patient  had  lost  twenty  pounds 
in  weight,  but  was  otherwise  in  good  general  condition. 

The  patient  was  placed  on  the  table  in  the  reverse  Trendelen- 
burg position  and  the  left  thoracic  cavity  opened  by  Cranwell's 
incision.  As  soon  as  the  pleura  was  opened  and  the  negative 
pressure  relieved,  the  stomach  and  other  herniated  viscera  re- 
turned to  the  abdomen.  The  left  lung  was  completely  collapsed. 
There  was  a  tear  in  the  diaphragm  about  five  inches  long,  ex- 
tending from  the  left  margin  to  the  esophageal  opening.  The 
liver,  spleen  and  other  abdominal  organs  could  plainly  be  seen. 
There  were  no  adhesions  except  between  the  margins  of  the 
hernial  opening  and  the  great  omentum,  and  these  were  easily 
separated. 

The  tear  in  the  diaphragm  was  repaired  with  chromicized  cat- 
gut sutures,  and  the  incision  in  the  chest  wall  closed  without 
drainage. 

The  patient  lost  little  blood,  showed  no  appreciable  shock,  and 
at  this  writing,  one  week  after  the  operation,  has  had  no  symp- 
toms to  cause  discomfort  or  give  anxiety.  The  patient  is  now 
on  general  diet  and  states  that  he  is  completely  relieved  of  his 
former  digestive  disturbance,  and  also  that  "it  is  a  great  satis- 
faction to  feel  the  food  go  to  the  proper  place." 


31 2 


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